Notice of privacy practices.


Please read this notice carefully.
Urology Northwest, PS 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 us 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 as well as billing and payment information related 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.
Examples of use and disclosure of protected health information for:
  • Infomation obtained by a nurse, physician or other members of your 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 your care.  This will help them stay informed about your care.


  • We request payment from your health insurance plan.  Health plans need information from us about your medical care.  Information provided to health plans may include your diagnoses, procedures performed or recommended care.

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 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: 1) medical quality review by your health plan; 2)accounting, legal risk management and insurance services.  3) audit functions, including fraud and abuse detection and compliance programs.
  • Quality of care and quality outcome audits conducted by Urology Northwest.  Results may be used in presentations, papers or research projects.  Patient names will not be disclosed.

Your Health Information Rights:

The health and billing records we create and store are the property of Urology Northwest, PS.  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.  We are not required to grant the request, but we will honor all requests granted.
  • Request and receive from us a paper copy of the most current Notice of Privacy for Protected Health Information.
  • 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 you can use to complete this request.
  • Ask us to change your health information.  You may give us this request in writing. You may write a letter of disagreement if your request is denied.  It will be stored in your medical record and included with any release of records.
  • When you request, we will provide you with a list of disclosures of your health information.  This list will not include disclosures to third party payors.  You may receive this information free one time every 12 months.  We will notify you of the cost involved if you request this information more than once every 12 months.
  • Ask that your health information be given to you by another means and at another location.  Please give us this request in writing signed and dated.
  • Cancel prior authorizations to use or disclose health information by giving us a written revocation.  Your revocation does not affect information already released and/or it does not affect action taken prior to obtaining the revocation.  Sometimes you cannot cancel an authorization if its purpose was to obtain insurance.

For help with understanding these rights, please contact: Candy Chapman, Practice Administrator during normal office hours (9am-5pm) Monday through Friday at 425-275-5547.

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 obtain the most recent notice by calling (425-275-5555), picking one up at our office (6005 244th St SW #111 Mountlake Terrace WA 98043) or on the web page at

Your Right to 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:

Candy Chapman, Practice Administrator Monday through Friday 9am-5pm 425-275-5547.

If you believe your privacy rights have been violated, you may discuss your concerns with any staff member, provide a written statement to Candy Chapman, Practice Administrator at our address or file a complaint with the US Secretary of Health and Human Services.

We respect your right to file a formal complaint with the US Secretary of Health and Human Services and will not retaliate against you in any way.


Notification to Family and/or Friends: Unless you object, we may release health information about you to a friend or family member who is involved in your care and/or to someone who helps you pay for your care.  We may tell your family and friends about your condition and if you are hospitalized.  In addition we may disclose health information about you to assist in disaster relief efforts.

Research:  to medical researchers if the research has been approved and policies are in place to protect the privacy of your health information.  We may also share information with medical researchers preparing to conduct a research project.

Funeral Directors/Coroners: consistent with applicable laws to allow them to carry out their duties.

Organ Procurement Organization: to persons who obtain, store or transplant organs.

Food and Drug Administration FDA); relating to problems with food, supplements and products.

Workers Compensation: To worker compensation companies, if you make a workers’ compensation claim.

Public Health and Safety Organizations: 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 and/or to report vital statistics such as births and deaths; to report abuse or neglect and to correctional institutions if you are jailed or in prison as necessary for your health and the health and safety of others. For law enforcment purposes such as when we receive a subpoena, court order or other legal process or you are a victim of a crime; for health and safety oversight; for work related conditions that could effect the health of others; to military authorities of the US and foreign military personnel; for judicial/administrative proceedings at your request or as directed by a subpoena or court order; for specialized government functions such as for national security.

Uses and disclosures of protected health information not in this notice will be made only as allowed or required by law or with your written authorization.

December 2008, updated July 2011