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Privacy notice for women entering treatment at Residence XII



Your health record contains personal information about you and your health. State and Federal law protects the confidentiality of this information. “Protected Health Information” is information about you including demographic information, that may identity you and that relates to your past, present or future physical or mental health or condition and related health care services. The confidentiality of alcohol and drug abuse patient records is specifically protected by Federal law and regulations. Residence XII is required to comply with these additional restrictions. This includes a prohibition, with very few exceptions, on informing anyone outside the program that you attend the program or disclosing any information that identifies you as an alcohol or drug abuser. The violation of Federal laws or regulation by this program is a crime. If you suspect a violation you may file a report to the appropriate authorities in accordance with Federal regulations.

Your Rights regarding Your PHI. You have the following rights regarding PHI we maintain about you:

  • Right of Access to Inspect and Copy. You have the right, which may be restricted only in certain limited circumstances, to inspect and copy PHI that may be used to make decisions about your care. We may charge a reasonable, cost-based fee for copies.
  • Right to Amend. If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information although we are not required to agree to the amendment.
  • Right to an Accounting of Disclosures. You have the right to request a copy of the required accounting of disclosures that we make of your PHI.
  • Right to Request Restrictions. You have the right to request a restriction or limitation on the use of your PHI for treatment, payment, or health care operations. We are not required to agree to your request.
  • Right to request Confidential Communication. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. We will accommodate reasonable requests and will not ask why you are making the request.
  • Right to a Copy of this Notice. You have the right to a paper copy of this notice.
  • Right to Complaint. You have the right to file a complain in writing to us or to the Secretary of Health and Human Services if you believe we have violated your privacy rights.

We will not retaliate against you for filing a complaint.


  • Treatment. Your PHI may be used and disclosed by your physician, counselor, program staff and others outside of our program that are involved in your care for the purpose of providing, coordinating, or managing you health care treatment and any related services. This includes coordination or management of your health care with a third party, consultation with other health care providers or referral to another provider for health care treatment. For example, we may disclose your protected health information from time-to-time to another physician or health care provider (e.g. a specialist or laboratory) who, at the request of the program, becomes involved in your care.
  • Payment. We will not use or disclose your PHI to obtain payment for your health care services without your written authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities.
  • Healthcare Operations. We may use your PHI to support the business activities of our program including, but not limited to, quality assessment activities, employee review activities, training of students , licensing, and conducting or arraigning for other business activities (e.g. billing or typing services) for us, provided we have a written agreement in place which addresses the privacy of your PHI.


  • Required by Law. We may use or disclose your PHI to the extent that the use or disclosure is required by law, made in compliance with the law, and limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures. For example, we must make disclosures to the Secretary of the Department of Health and Human services for the purpose of investigating or determining our compliance with the requirements or the Privacy Rule.
  • Audit and Evaluation. We may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies and organizations that provide financial assistance to the program (such as third party payers) and peer review organizations performing utilization and quality control. If we disclose PHI to a health oversight agency, we will have an agreement in place that requires the agency to safeguard the privacy of your information.
  • Medical Emergencies. We may use or disclose your PHI in a medical emergency situation to medical personnel only.
  • Child Abuse or Neglect. We may disclose your PHI to a state or local agency that is authorized by law to receive reports of child abuse or neglect. However, the information we disclose is limited to only that information which is necessary to make the mandated report.
  • Research. We may disclose PHI to researchers if (a) an Institutional Review Board reviews and approves the research and a waiver to the authorization requirement; (b) the researchers establish protocols to ensure the privacy of your PHI; (c) the researchers agree to maintain the security of your PHI in accordance with applicable laws and regulations; and (d) the researchers agree not to redisclose your protected health information except back to Residence XII.
  • Criminal Activity on Program Premises/Against Program Personnel. We may disclose your PHI to law enforcement officials if you have committed a crime on program premises or against program personnel.
  • Qualifies Service Organization. Provides services to a program, such as data processing, bill collecting, dosage preparations. Laboratory analyses, or legal, medical accounting, or other professional services, or services to prevent or treat child abuse or neglect, including training on nutrition and child care and individual and group therapy. If a QSO has more than incidental access to PHI and/or the functions or services relate to payment, then a Business Associate Agreement must be utilized otherwise only a Qualified Organization Agreement is required. In the case the service or function is from a health care provider performing services to treat a patient, then a Business Associate Agreement is not required (because the provider will have a direct patient provider relationship or the provider will have been identified in the Consent For Treatment.)
  • Court Order. We may disclose your PHI if the court issues an appropriate order and follows required procedures.


We must obtain written authorization from you for other uses and disclosures of your PHI.


This Notice of Privacy Practices describes how we may use and disclose your protected health information (“PHI”) in accordance with all applicable law. It also describes your rights regarding how you may gain access to and control your PHI. We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of this Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will make available a revised Notice of Privacy Practices by posting a copy on our website (, sending a copy to you in the mail upon request, or providing one to you at your next appointment.


If you have any questions about this Notice of Privacy Practices, please contact our Privacy Officer:

Lori Fregin

12029 113th Ave NE. Kirkland, WA. 98034

[email protected]


If you believe we have violated your privacy rights, you may file a complaint in writing to us by notifying our Privacy Officer:

Lori Fregin

12029 113th Ave NE. Kirkland, WA. 98034

(425) 823-8844 or by email, [email protected]

We will not retaliate against you for filing a complaint.

You may also file a complaint with the U.S. Secretary of Health and Human services as follows:

200 Independence Avenues S.W.

Washington, D.C. 20201

(202) 619-0257

The effective date of this Notice is April 14, 2003

Notice Updated with change of Privacy Officer, July 21, 2003

PDF Download of Privacy Practices