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Olympia Therapy PLLC

1534 Bishop Rd SW Tumwater WA 98512    360.357.2370 office.   360.357.2374 fax


As part of my professional practice, I maintain personal information about you and your health. State and federal law protects such information by limiting its uses and disclosures. “Protected Health Information” (“PHI”) is information about you, including demographic information, that may identify you or be used to identify you, and that relates to your past, present or future physical or mental health condition, the provision of health care services, or the past, present or future payment for the provision of health care.

Your Rights Regarding Your PHI The following are your rights regarding PHI I 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 your PHI that I maintain. I may charge a reasonable, cost-based fee for copies.

  • ❖  Right to Amend. If you feel that the PHI I have about you is incorrect or incomplete, you may ask me to amend the information although I am 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 I make of your PHI.

  • ❖  Right to Request Restrictions. You have the right to request restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. I am not required to agree to your


  • ❖  Right to Request Confidential Communication. You have the right to request that I communicate with you in a certain way or at a certain location. I 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 of Complaint. You have the right to file a complaint in writing with me or with the Secretary of Health and Human Service if you believe I have violated your privacy rights. I will not retaliate against you

    for filing a complaint.

    My Uses and Disclosures of PHI for Treatment, Payment, and Health Care Operations
    Treatment: I may use your PHI for the purpose of providing you with health care treatment. To coordinate and manage your care, I may disclose your PHI to others of your current providers, and to the extent you have not raised an objection in writing to your prior providers, or to other persons, including family members, involved in your care.
    Payment: I may use your PHI in connection with billing statements and my system for tracking charges and credits to your account. In addition, but with your authorization, I may disclose your PHI to third payers to obtain information concerning benefit eligibility, coverage, and remaining availability, as well as to submit claims for payment and to disclose PHI for medical necessity and quality assurance reviews.
    Health Care Operations: I may use and disclose to you PHI for the health care operations of my professional practice in support of the functions of treatment and payment. Such disclosures would be to Business Associates for health care education, or to provide planning, quality assurance, peer review, administrative, legal, or financial services to assist in the delivery of your health care.
    Other Uses and Disclosures That Do Not Require Your Authorization or Opportunity to Object
    Required by Law. I 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. Examples are public health reports, abuse and neglect reports, law enforcement reports, and reports to coroners and medical examiners in connection with investigation of deaths. I also must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining my compliance with the requirements of the Privacy Rule. Health Oversight. I may disclose your PHI to a health oversight agency for activities authorized by law, such as my professional licensure. Oversight agencies also include government agencies and organizations that audit their provision of payment to me (such as third-party payers). Threat of Health or Safety. I may disclose your PHI when necessary to minimize an imminent danger to the health or safety of you or any other individual. Business Associates. I may disclose your PHI to Business Associates that are contracted by me to perform health care operations or payment activities on my behalf, which may involve their collection, use, or disclosure of your PHI. My contract with them must require them to safeguard the privacy of your PHI. Compulsory Process. I will disclose your PHI if a court of competent jurisdiction issues an appropriate order. I will also disclose your PHI if (1) you and I have each been notified in writing at least fourteen days in advance of a subpoena or other legal demand, identifying the PHI sought, and the date by which a protective order must be obtained to avoid my compliance, (2) no qualified judicial or administrative protective order has been obtained, (3) I have received satisfactory assurances that you received notice of an opportunity to have limited or quashed the discovery demand, and (4) such time has elapsed. Electronic Health Record. For medical recordkeeping, our office uses Practice Fusion, which is supported by advanced encryption and is fully HIPPA compliant. Paper records can be scanned, uploaded securely and duplicates destroyed. See reliable her.html for details.

    Uses and Disclosures of PHI With Your Written Authorization

    I will make other uses and disclosures of your PHI only with your written authorization. You may revoke such authorization in writing at any time, unless I have taken substantial action in reliance on the authorization such as providing you with health care services for which I must submit subsequent claim(s) for payment. This Notice
    This Notice of Privacy Practices informs you of how I may use and disclose your protected health information (“PHI”) and your rights regarding your PHI. I am required by law to maintain the privacy of your PHI and to provide you with notice of my legal duties and privacy practices with respect to your PHI. I am required to abide by the terms of the Notice of Privacy Practices. I reserve the right to change the terms of my Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that I maintain at that time. I will make available a revised Notice of Privacy Practices by providing you a copy upon your request or at your next appointment.

    Contact Information

    If you have any questions about this Notice of Privacy Practices, please contact the office at:

    Olympia Therapy PLLC
    1534 Bishop Rd SW, Tumwater, WA 98512 (360) 357.2370 office or (360) 357.2374 fax

    Complaints: If you believe someone has violated your privacy rights, you may file a complaint in writing to the office. We will not retaliate against you for filing a complaint. You may also file a complaint with the Secretary of the Department of Health and Human Services.



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