HIPAA Compliance
Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed, and how you can get access to this information. This information will include Protected Health Information (PHI), as that term is defined in privacy regulations issued by the United States Department of Health and Human Services pursuant to the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and, as applicable, RCW Chapter 70.02 entitled “Medical Records - Health Care Access and Disclosure.” Please review it carefully. Interlake Psychiatric Associates, PLLC respects your privacy. We understand that your personal health information is very sensitive. We will not disclose your information to others unless you tell us to do so, or unless the law authorizes or requires us to do so. The law protects the privacy of the health information we create and obtain in providing our care and services to you. For example, your protected health information includes your symptoms, test results, diagnoses, treatment, health information from other providers, and billing and payment information relating to these services. Federal and state law allows us to use and disclose your protected health information for purposes of treatment and health care operations. State law requires us to get your authorization to disclose this information for payment purposes.

Protected Health Information:

Protected health information means individually identifiable health information:
  • Transmitted by electronic media;
  • Maintained in any medium described in the definition of electronic media; or
  • Transmitted or maintained in any other form or medium.

Examples of Use and Disclosures of Protected Health Information for Treatment, Payment, and Health Operations

For treatment:

  • Information obtained by a nurse, physician, clinical psychologist, MSW, therapist, or other member of our health care team will be recorded in your medical record and used to help decide what care may be right for you.
  • We may also provide information to others providing you care. This will help them stay informed about your care

For payment:

In Washington State, written patient permission is required to use or disclose PHI for payment purposes, including to your health insurance plan. We will have you sign another form Assignment of Benefits or similar form for this purpose (RCW 70.02.030(6)). Health plans need information from us about your medical care. Information provided to health plans may include your diagnoses, procedures performed, or recommended care.

For health care operations:

  • We use your medical records to assess quality and improve services.
  • We may use and disclose medical records to review the qualifications and performance of our health care providers and to train our staff.
  • We may contact you to remind you about appointments and give you information about treatment alternatives or other health-related benefits and services.
  • We may use and disclose your information to conduct or arrange for services, including:
    • medical quality review by your health plan;
    • accounting, legal, risk management, and insurance services;
    • audit functions, including fraud and abuse detection and compliance programs.

Your Health Information Rights

The health and billing records we create and store are the property of Interlake Psychiatric Associates, PLLC. The protected health information in it, however, generally belongs to you. You have a right to:

  • Receive, read, and ask questions about this Notice;
  • Ask us to restrict certain uses and disclosures. You must deliver this request in writing to us. We are not required to grant the request. But we will comply with any request granted;
  • Request and receive from us a paper copy of the most current Notice of Privacy Practices for Protected Health Information (“Notice”);
  • Request that you be allowed to see and get a copy of your protected health information. You may make this request in writing. We have a form available for this type of request.
  • Have us review a denial of access to your health information—except in certain circumstances;
  • Ask us to change your health information. You may give us this request in writing. You may write a statement of disagreement if your request is denied. It will be stored in your medical record, and included with any release of your records.
  • When you request, we will give you a list of disclosures of your health information. The list will not include disclosures to third-party payors. You may receive this information without charge once every 12 months. We will notify you of the cost involved if you request this information more than once in 12 months.
  • Ask that your health information be given to you by another means or at another location. Please sign, date, and give us your request in writing.
  • Cancel prior authorizations to use or disclose health information by giving us a written revocation. Your revocation does not affect information that has already been released. It also does not affect any action taken before we have it. Sometimes, you cannot cancel an authorization if its purpose was to obtain insurance.

For help with these rights during normal business hours, please contact:

Privacy Officer
Interlake Psychiatric Associates, PLLC
2025 112th Avenue NE, Suite 200
Bellevue, WA 98004
Tel: (425) 462-9511

Psychotherapy Notes:

Notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of a conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual’s medical record. Psychotherapy notes excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date. An authorization to use or disclose psychotherapy notes is required except if used by the originator of the notes for treatment, to a person or persons reasonably able to prevent or lessen the threat (including the target of the threat), if the originator believes in good faith that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public, if the notes are to be used in the course of training students, trainees or practitioners in mental health; to defend a legal action or any other legal proceeding brought forth by the patient; when used by a medical examiner or coroner; for health oversight activities of the originator; or when required by law.

Our Responsibilities

We are required to:

  • Keep your protected health information private;
  • Give you this Notice;
  • Follow the terms of this Notice.

We have the right to change our practices regarding the protected health information we maintain. If we make changes, we will update this Notice. You may receive the most recent copy of this Notice by calling and asking for it or by visiting our office or medical records department to pick one up.

To Ask for Help or Complain

If you have questions, want more information, or want to report a problem about the handling of your protected health information, you may contact:

Privacy Officer
Interlake Psychiatric Associates, PLLC
2025 112th Avenue NE, Suite 200
Bellevue, WA 98004
Tel: (425) 462-9511

If you believe your privacy rights have been violated, you may discuss your concerns with the Privacy Officer. You may send a written complaint to the Washington State Department of Health at:

510 – 4th Avenue W, Suite 404
Seattle, WA 98119

You may also file a complaint with the U.S. Secretary of Health and Human Services. We respect your right to file a complaint with us or with the U.S. Secretary of Health and Human Services. If you complain, we will not retaliate against you.

Other Disclosures and Uses of Protected Health Information

Notification of Family and Others

Unless you object, we may release health information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. We may tell your family or friends your condition and that you are in a hospital. This would be limited to your name and general health condition (for example, “critical,” “poor,” “fair,” “good” or similar statements). In addition, we may disclose health information about you to assist in disaster relief efforts.

You have the right to object to this use or disclosure of your information. If you object, we will not use or disclose it.

We may use and disclose your protected health information without your authorization as follows:

  • With Medical Researchers—if the research has been approved and has policies to protect the privacy of your health information. We may also share information with medical researchers preparing to conduct a research project.
  • To the Food and Drug Administration (FDA) relating to problems with food, supplements, and products.
  • To Comply With Workers’ Compensation Laws—if you make a workers’ compensation claim.
  • For Public Health and Safety Purposes as Allowed or Required by Law:
  • to prevent or reduce a serious, immediate threat to the health or safety of a person or the public.
  • to public health or legal authorities
  • to protect public health and safety
  • to prevent or control disease, injury, or disability
  • to report vital statistics such as births or deaths.
  • To Report Suspected Abuse or Neglect to public authorities.
  • To Correctional Institutions if you are in jail or prison, as necessary for your health and the health and safety of others.
  • For Law Enforcement Purposes such as when we receive a subpoena, court order, or other legal process, or you are the victim of a crime.
  • For Health and Safety Oversight Activities. For example, we may share health information with the Department of Health.
  • For Disaster Relief Purposes. For example, we may share health information with disaster relief agencies to assist in notification of your condition to family or others.
  • For Work-Related Conditions That Could Affect Employee Health. For example, an employer may ask us to assess health risks on a job site.
  • To the Military Authorities of U.S. and Foreign Military Personnel. For example, the law may require us to provide information necessary to a military mission.
  • In the Course of Judicial/Administrative Proceedings at your request, or as directed by a subpoena or court order.
  • For Specialized Government Functions. For example, we may share information for national security purposes.
  • To Coroners, Medical Examiners, Funeral Directors. We may disclose PHI to a coroner or medical examiner to identify a deceased person and determine the cause of death. In addition, we may disclose PHI to funeral directors, as authorized by law, so that they may carry out their jobs.
  • Organ and Tissue Donations. If you are an organ donor, we may use or disclose PHI to organizations that help procure, locate and transplant organs in order to facilitate an organ, eye or tissue donation and transplantation.
  • Incidental Disclosures. We may use or disclose PHI incident to a use or disclosure permitted by the HIPAA Privacy Rule so long as we have reasonably safeguarded against such incidental uses and disclosures and have limited them to the minimum necessary information.
  • Limited Data Set Disclosures. We may use or disclose a limited data set (PHI that has certain identifying information removed) for purposes of research, public health, or health care operations. This information may only be disclosed for research, public health and health care operations purposes. The person receiving the information must sign an agreement to protect the information.

Special Authorizations

Certain federal and state laws that provide special protections for certain kinds of personal health information call for specific authorizations from you to use or disclose information. When your personal health information falls under these special protections, we will contact you to secure the required authorizations to comply with federal and state laws such as:

Uniform Health Care Information Act (RCW 70.02)
Sexually Transmitted Diseases (RCW 70.24.105)
Drug and Alcohol Abuse Treatment Records (RCW 70.96A.150)
Mental Health Services for Minors (RCW 71.05.390-690)
Communicable and Certain Other Diseases Confidentiality (WAC 246-100-016)
Confidentiality of Alcohol and Drug Abuse Patients (42 CFR Part 2)

If we need your health information for any other reason that has not been described in this notice, we will ask for your written authorization before using or disclosing any identifiable health information about you. Most important, if you choose to sign an authorization to disclose information, you can revoke that authorization at a later time to stop any future use and disclosure.

Other Uses and Disclosures of Protected Health Information

Uses and disclosures not in this Notice will be made only as allowed or required by law or with your written authorization.

Effective Date:

April 14, 2003

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