Our Commitment to Your Privacy

Puyallup Bliss AFH LLC is committed to protecting the privacy of your health information. We are required by law to:

• Maintain the privacy of your Protected Health Information (PHI)

• Provide you with this Notice of our legal duties and privacy practices

• Follow the terms of the Notice currently in effect

• Notify you if we are unable to agree to a requested restriction

• Accommodate reasonable requests to communicate health information by alternative means or locations

What is Protected Health Information (PHI)?

Protected Health Information includes any information about you that:

• Relates to your past, present, or future physical or mental health condition

• Relates to the provision of healthcare services to you

• Relates to payment for healthcare services

• Identifies you or could be used to identify you

Examples include:

• Medical records and care plans

• Medication lists and physician orders

• Progress notes and assessments

• Billing and insurance information

• Photographs and video recordings

• Any communication about your care

How We May Use and Disclose Your Health Information

Without Your Written Authorization:

1. For Treatment: We may use and disclose your PHI to provide, coordinate, or manage your healthcare and related services. This includes:

• Sharing information with physicians, nurses, and other healthcare providers

• Coordinating care with hospitals, pharmacies, and specialists

• Consulting with other healthcare professionals about your treatment

• Providing information to family members or others involved in your care (with your consent)

Example: We may share your medication list with your physician to ensure proper care coordination.

2. For Payment: We may use and disclose your PHI to obtain payment for services provided. This includes:

• Billing you, your insurance company, or other responsible parties

• Submitting claims to Medicare, Medicaid, or private insurance

• Verifying insurance coverage and benefits

• Collection activities if payment is not received

Example: We may send your insurance company information about services you received to obtain payment.

3. For Healthcare Operations: We may use and disclose your PHI for operational purposes, including:

• Quality improvement and assessment activities

• Staff training and education

• Licensing and accreditation activities

• Business planning and management

• Legal and compliance activities

Example: We may review your care plan to evaluate the quality of care provided.

4. As Required by Law: We will disclose your PHI when required by federal, state, or local law, including:

• Reporting abuse, neglect, or domestic violence to authorities

• Responding to court orders or subpoenas

• Providing information to law enforcement in specific circumstances

• Reporting certain diseases to public health authorities

• Complying with workers' compensation laws

5. For Public Health Activities: We may disclose your PHI for public health purposes, such as:

• Preventing or controlling disease, injury, or disability

• Reporting adverse events related to medications or medical devices

• Notifying authorities of suspected abuse or neglect

• Reporting births and deaths

6. Health Oversight Activities: We may disclose your PHI to health oversight agencies for:

• Audits and investigations

• Inspections and licensure activities

• Monitoring compliance with regulations

7. Coroners, Medical Examiners, and Funeral Directors: We may disclose your PHI to coroners, medical examiners, or funeral directors as necessary to carry out their duties.

8. Research: We may use or disclose your PHI for research purposes only with your authorization or as permitted by law with appropriate safeguards.

9. To Avert a Serious Threat: We may use or disclose your PHI if we believe it is necessary to prevent a serious threat to your health or safety or the health or safety of others.

Uses and Disclosures Requiring Your Written Authorization

Authorization Required: For uses and disclosures not described above, we will obtain your written authorization, including:

• Marketing purposes

• Sale of your PHI

• Psychotherapy notes (if applicable)

• Other uses not covered by this Notice

Right to Revoke: You may revoke your authorization at any time by submitting a written request. The revocation will not affect any uses or disclosures already made based on your authorization.

Your Rights Regarding Your Health Information

1. Right to Inspect and Copy: You have the right to inspect and obtain a copy of your health information, including:

• Medical records and care plans

• Billing records

• Other records used to make decisions about your care

How to Request: Submit a written request to our Privacy Officer. We may charge a reasonable fee for copying and mailing costs.

Timeframe: We will respond within 30 days of receiving your request.

Denial: In certain limited circumstances, we may deny your request. You may request a review of the denial.

2. Right to Amend: If you believe your health information is incorrect or incomplete, you have the right to request an amendment.

How to Request: Submit a written request to our Privacy Officer explaining the reason for the amendment.

Timeframe: We will respond within 60 days of receiving your request.

Denial: We may deny your request if the information:

• Was not created by us

• Is not part of the records we maintain

• Is accurate and complete

If denied, you may submit a statement of disagreement.

3. Right to an Accounting of Disclosures: You have the right to receive a list of certain disclosures we have made of your PHI.

What's Included: The accounting will include:

• Date of disclosure

• Name of the person or organization receiving the information

• Brief description of the information disclosed

• Purpose of the disclosure

What's Not Included:

• Disclosures for treatment, payment, or healthcare operations

• Disclosures made to you or with your authorization

• Disclosures for national security purposes

• Disclosures to correctional institutions or law enforcement

How to Request: Submit a written request to our Privacy Officer.

Timeframe: We will respond within 60 days. The first accounting in a 12-month period is free; subsequent requests may incur a reasonable fee.

4. Right to Request Restrictions: You have the right to request restrictions on how we use or disclose your PHI for treatment, payment, or healthcare operations.

How to Request: Submit a written request to our Privacy Officer specifying:

• What information you want to limit

• How you want it limited (use, disclosure, or both)

• To whom the limits apply

Our Response: We are not required to agree to your request, except in the case where you pay out-of-pocket in full for a service and request that we not disclose information to your health plan for payment purposes.

5. Right to Request Confidential Communications: You have the right to request that we communicate with you about your health information in a specific way or at a specific location.

Example: You may request that we contact you at work instead of home, or by mail instead of phone.

How to Request: Submit a written request to our Privacy Officer. We will accommodate reasonable requests.

6. Right to a Paper Copy of This Notice: You have the right to receive a paper copy of this Notice at any time, even if you have agreed to receive it electronically.

How to Request: Contact our Privacy Officer or visit our website at Puyallupblissafh.com.

7. Right to Be Notified of a Breach: You have the right to be notified if your unsecured PHI is breached.

Our Obligation: We will notify you promptly if a breach occurs that may have compromised the privacy or security of your information.

Our Responsibilities

We are required to:

• Maintain the privacy and security of your PHI

• Provide you with this Notice of our privacy practices

• Follow the terms of the Notice currently in effect

• Notify you if we are unable to agree to a requested restriction

• Notify you if a breach of your unsecured PHI occurs

We reserve the right to:

• Change our privacy practices and the terms of this Notice

• Make new provisions effective for all PHI we maintain, including information created or received before the change

If we make changes:

• We will post the revised Notice on our website

• We will provide you with a copy of the revised Notice

• The effective date will be noted on the first page

Complaints

If you believe your privacy rights have been violated, you have the right to file a complaint.

How to File a Complaint:

With Our Facility:
Privacy Officer: Mandeep Dhindsa
Puyallup Bliss AFH LLC
604 22nd Ave Ct SE
Puyallup, WA 98372
Phone: (253) 455-5057
Email: Puyallupblissafh@gmail.com

With the U.S. Department of Health and Human Services:
Office for Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201
Phone: 1-877-696-6775
Website: www.hhs.gov/ocr/privacy/hipaa/complaints

No Retaliation: You will not be penalized, retaliated against, or denied services for filing a complaint.

Contact Information

Privacy Officer:
Mandeep Dhindsa, Office Manager

Facility Contact:
Puyallup Bliss AFH LLC
604 22nd Ave Ct SE
Puyallup, WA 98372

Phone: (253) 455-5057 or (206) 913-9361
Email: Puyallupblissafh@gmail.com
Website: Puyallupblissafh.com

State Licensing Information

Puyallup Bliss AFH LLC is licensed by the Washington State Department of Social and Health Services (DSHS).
License Number: 758137