Your Rights, Our Responsibilities

This Notice describes how student information about you may be used and disclosed and how you can get access to this information.

Please review carefully

Changes to the Terms of This Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon your request, in our office, and below.
Updated: January 2023

This Notice of Privacy Practices applies to the following organizations:

Organization:      Mandorla Wellness PLLC

Contact:                Tina Willett, MSN MEd RN CRRN CWCN

Email:                    Contact Us Here

Arlington, WA 98223

---

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get An Electronic or Paper Copy of Your Student Record

• When our organization is the HIPAA Covered Entity providing care.
  • You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
  • We will provide a copy or a summary of your health information, usually within 15 days of your request. We may charge a reasonable, cost-based fee.
• When our organization is a business associate to another care provider, all requests shall be forwarded to the Covered Entity by you.

Ask us to Correct Your Medical Record

• When our organization is the HIPAA Covered Entity providing care.
  • You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
  • We may say “no” to your request, but we’ll tell you why in writing within 15 days.
• When our organization is a business associate to another care provider, all requests shall be forwarded to the Covered Entity by you.

Request Confidential Communications

• You can ask us to contact you in a specific way (for example home or office phone) or to send mail to a different address.
• We will say “yes” to all reasonable requests.

Ask us to Limit What We Use or Share

• You can ask us not to use or share certain health information for treatment, payment, or our operations.
  • We are not required to agree to your request, and we may say “no” if it would affect your care.
• If you pay for a service or healthcare item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer.
  • We will say “yes” unless a law requires us to share that information.

Get a List of Those With Whom We’ve Shared Information

• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
• We will include all the disclosures except for those about
  • Treatment, payment, and healthcare operations, and certain other disclosures (such as any you asked us to make).
• We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a Copy of This Privacy Notice

• You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose Someone to Act for You

• When our organization is the HIPAA Covered Entity providing care.
  • If you have given someone medical power of attorney, or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
  • We will make sure the person has authority and can act for you before we take any action.
• When our organization is a business associate to another care provider, all requests shall be forwarded to the Covered Entity by you.

File a Complaint If You Feel Your Rights are Violated

• You can complain if you feel we have violated your rights by contacting us directly.
• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting the U.S. Department of Health & Human Services online.
  • We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference on how we share your information in the situations below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In These Cases, You Have Both the Right and the Choice to Tell Us To:

• Share information with your family, close friends, or others involved in your case.
• Share information in a disaster relief situation.
• Include your information in a facility directory.

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and immediate threat to health or safety.

In These Cases, We Never Share Your Information, Unless You Give Us Written Permission:

• Marketing purposes
• Sale of your information
• Most sharing of psychotherapy notes

Our Uses and Disclosures

How do we typically use or share your health information?

We typically use or share your health information in the following ways:

Treat You

• We can use your health information and share it with other professionals who are treating you.
• Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run Our Organization

• We can use or share your health information to run our practice, improve your care, and contact you when necessary.
• Example: We use health information about you to manage your treatment and services.

Bill For Your Services

• We can use and share your health information to bill and get payment from health plans and other entities.
• Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information?

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We must meet many conditions in the law before we can share your information for these purposes. For more information visit the U.S. Department of Health & Human Services – HIPAA website.

Help With Public Health and Safety Issues

We can share health information about you for certain situation such as:

• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone’s health or safety

Work With A Medical Examiner or Funeral Director

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address Workers’ Compensation, Law Enforcement, and Other Government Requests

We can use or share information about you:

• For workers’ compensation claims
• For law enforcement purposes or with a law enforcement official
• With health oversight agencies for activities authorized by law
• For special government functions such as military

Respond to Lawsuits and Legal Actions

We can share health information about you in response to a court or administrative order, or in response to a subpoena

Student records are governed by Family Educational Rights and Privacy Act (FERPA) and the Washington Uniform Health Care Information Act, RCW 70.02. Laws in Washington provide greater protections in some cases.  When required by law, we will not share the following type of information without your written permission:

• Mental health services records
• Sexually transmitted diseases records
• Treatment records for drug and alcohol abuse
• HIV/AIDS records

Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
• Mandorla Wellness does not discriminate or treat patients differently on the basis of age, race, color, national origin, sex, sexual orientation, gender identity or expression, religion, or disability. WSU will provide reasonable accommodations when necessary to communicate with and treat patients effectively. Mandorla Wellness complies with all state and federal laws  surrounding nondiscrimination.