Privacy Policy

Home » Privacy Policy

Why this notice?

We have always taken seriously our responsibility to protect your personal health information and to coordinate your care with referring physicians, family and health insurance plans.

Under a federal law called the Health Insurance Portability and Accountability Act (HIPAA), covered health care organizations across the nation, including RNW, must have a written Notice of Privacy Practices, must provide you with a copy, and must have a signed acknowledgment that you received the copy.

We must also post a notice of our Privacy Practices in our waiting rooms.

If you would like a copy of this notice to take home with you, please ask for a one at the reception desk.

Thank you.

Retina Northwest P.C.



Effective Date: April 14, 2003



This is your Health Information Privacy Notice from Retina Northwest (RNW). This notice describes how we protect the personal health information we have about you and how we may use and disclose this information.

Protected health information (“PHI”) is health information that contains identifiers, such as your name, social security number or other information that reveals who you are. It may be in the form of written or electronic records or spoken words.

We are required by law to give you this notice. It will tell you about:

  1. The ways in which we may use and disclose health information about you;
  2. The situations in which we are required to obtain written authorization from you to release personal health information; and
  3. Your rights and our obligations regarding the use and disclosure of that information.


Your confidentiality is important to us. We have policies and procedures and other safeguards to help protect your PHI from improper use and disclosure. Sometimes we are allowed by law to use and disclose certain PHI without your written permission. We describe these uses and disclosures below. How much PHI is used or disclosed depends on the intended purpose of the use or disclosure. In some cases, only a limited amount is disclosed, such as when we call to remind you of your appointment with us. At other times, we may need to use or disclose more PHI, such as when we are coordinating your health care with another physician.

Treatment. We may use PHI to provide you with medical treatment or services. We may disclose PHI to our staff of doctors, nurses, technicians, office staff or other personnel who are involved in taking care of you and your health. We may disclose PHI to health care providers who are not on our staff. We may disclose PHI to family members who may be part of your medical care outside this office and may require information to provide that care

For example, if you are being treated for macular degeneration, we may share your PHI with your primary physician, your ophthalmologist, and a family member that is assisting you in coordinating your care.

Payment. We may use and disclose PHI to obtain payment for services we, or other providers who are coordinating your care, provide for you. We may disclose PHI to other organizations and providers for payment activities unless disclosure is prohibited by law.

For example, we disclose PHI when billing and collecting payment from your health insurance company. We also tell your health plan about a treatment you are going to receive to obtain approval or to determine whether your plan will pay for the treatments.

Health Care Operations. We may use and disclose PHI in relation to health care operations. We may disclose PHI to administer and support our business activities or the business activities of other health care organizations, such as your insurance plan.

For example, PHI may be used for quality assessment and improvement, training and evaluation of staff, licensing, and accreditation.

Business Associates. We may disclose PHI to other individuals and organizations that help us with our business activities. If we share your PHI for this purpose, the individuals and organizations must agree to protect your privacy.

Appointment Reminders. We may contact you as a reminder that you have an appointment for treatment or medical care at the office. These reminders may be made by postcard, phone, e-mail, or voicemail.

Treatment Alternatives and Services. We may tell you about or recommend possible treatment options or alternatives that may be of interest to you. We may tell you about health related products or services that may be of interest to you.

Legal and Governmental Purposes: We may use and disclose PHI in the following circumstances:

Required by law. We may disclose PHI when we are required to do so by state and federal law.

Public Health and Safety. We may disclose PHI to an authorized public health authority. Public health activities include many functions needed to promote and protect public health and safety, including the prevention or control of disease, injury, or disability, the reporting of vital statistics and the investigation or tracking of problems with prescription drugs and medical devices.

Abuse and Neglect. We may disclose PHI to government entities authorized to receive reports regarding abuse, neglect, or domestic violence.

Health Oversight Activities. We may disclose PHI to health oversight agencies for certain activities such as audits, examinations, investigations, inspections and licensures.

Legal proceedings. We may disclose PHI in responding to an order of a court or administrative agency, and in certain cases, in response to a subpoena, discovery request, or other lawful process. We may also use and disclose PHI to the extent permitted by law without your authorization in defending a lawsuit or arbitration.

Law enforcement. We may disclose PHI to authorized officials for law enforcement purposes. For example, we may use or disclose PHI to report a crime on our premises or help identify or locate someone.

Military activity, national security, Protective Services for the President and Others. We may release PHI if required by military command or other government authorities.

Coroners, funeral directors. We may disclose PHI to a coroner or funeral director.

Inmates. Inmates do not have the same rights to control their PHI as other individuals. We may disclose your PHI to the correctional institution or the law enforcement official for certain purposes such as, for example, to protect your health or safety or someone else’s.

Other Special circumstances: We may use and disclose PHI under the following circumstances:

Communication with family and others when you are present. We may use and disclose PHI to a member of your family, a relative, a close friend, or any other person who is directly involved in your health care. If you object, please tell us and we won?t discuss your PHI or we will ask the other person to leave.

Communication with family and others when you are not present. We may use and disclose PHI about you when you are not present or are unable to make a health care decision for yourself. In these instances, we will use our professional judgment to determine that disclosure is in your best interest.

For example, we may disclose PHI to the person who is waiting for you at the hospital during an outpatient procedure.

Organ and Tissue Donation. If you are an organ donor, we may release PHI to organizations that handle organ and tissue procurement and transplantation.

Research. RNW participates in important health research. Some of our research may involve medical procedures and some is limited to collection and analysis of health data. Your PHI can generally be used or disclosed for research without your permission if an Institutional Review Board (IRB) approves such use or disclosure. If you are involved in research involving a medical procedure, we will inform you prior to participation of your privacy rights.

Serious Threat to Health or Safety. We may use and disclose your PHI if we believe it is necessary to avoid a serious threat to your health or safety or to someone else?s.

Marketing. RNW may use and disclose your PHI to contact you about benefits, services or supplies that we can offer you related to your health care at RNW.

Written Authorizations to Release Personal Health Information

Other uses and disclosures of PHI not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you give us Authorization to use or disclose PHI, you may revoke that Authorization, in writing, at any time. If you revoke your Authorization, we will no longer use or disclose information about you for the reasons covered by your written Authorization, but we cannot take back any uses or disclosures already made with your permission.

If you would like to ask us to disclose your PHI, please contact the Medical Records & Privacy Department at 503-274-2121 for an authorization form.


You may exercise any of the rights described below, or ask questions about these rights by contacting the Medical Records and Privacy Office at 503-274-2121. We will provide you a copy of the forms needed for submission of your written requests.

You have the following rights regarding health information we maintain about you:

Right to See and Receive Copies. You have the right to see and receive copies of your health information, such as medical and billing records. Requests must be in writing and we may charge a reasonable fee for the cost of producing and mailing copies.

We may deny your request in certain limited circumstances. We will tell you why we are denying your request. In some cases, you may request that our denial be reviewed. If the law gives you a right to have our denial reviewed, we will select a licensed health care professional to review your request and our denial. The person conducting the review will not be the person who denied your request, and we will comply with the outcome of the review.

Right to Request an Amendment. If you believe health information we have about you is incorrect or incomplete, you may ask that we correct or add to the record.

Your request for an amendment must be in writing and must provide the reasons for your request. We will respond in writing after receiving your request. In certain cases we may deny your request. You may respond by filing a written statement of disagreement with us and ask that the statement be included with your PHI.

Right to an Accounting of Disclosures. You have the right to request, in writing, an “accounting of disclosures.” This is a list of the disclosures of your PHI for purposes other than treatment, payment, health care operations, and a limited number of special circumstances involving national security, correctional institutions and law enforcement. The list will also exclude any disclosures we have made based on your written authorization. We may charge you a reasonable fee if you request more than one accounting of disclosure per year.

To obtain this list, you must submit your request in writing. It must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. The first list you request within a 12-month period will be free.

Right to Request Restrictions. You have the right to request, in writing, a restriction or limitation on the PHI we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for it, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had.

We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide emergency treatment or we are required by law to use or disclose the information.

We are required to agree to your request if you pay for treatment, services, supplies and prescriptions “out of pocket” and you request the information not be communicated to your health plan for payment or health care operations purposes.  There may be instances where we are required to release this information if required by law.

Right to Request Alternate Means of Communication. You have the right to request that we communicate with you about medical matters at a different address or by a different means. For example, you can ask that we only contact you at work or only by mail. We will agree to reasonable requests. However, we are permitted to charge you for any additional cost of sending your PHI or contacting you via these alternate ways.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice upon request.


We reserve the right to change this notice, and to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. If we change any of the practices described in this Notice, we will post the revised Notice in our medical offices.


We will inform you if there is a breach of your unsecured health information.


If you believe your privacy rights have been violated or you disagree with a decision we made about access to your health information, you may file a written complaint with:
Retina Northwest Privacy Officer
2525 NW Lovejoy St. #100
Portland OR 97210
For more information on how to file a written complaint, call the Privacy Officer at 503-274-2121. You may also file a complaint with the Secretary of the Department of Health and Human Services. You will not be penalized if you file a complaint about our privacy practices.


  For the health and safety of all patients and staff, note our current guidelines (subject to change without notice).


· One family member/friend is allowed to accompany the patient.