Aloha Dermatology Clinic
Susan Tobey Denman, MD
18345 SW Alexander Street, Suite B
Aloha, OR 97003
(503) 649-1272 fax
Office Hours: Mon-Thurs 9:00-5:00
Diseases of the skin, hair, and nails.
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.PLEASE REVIEW IT CAREFULLY.
If you have any questions about this notice, please contact Dr. Susan Denman of our office at (503) 649-9477
18345 SW Alexander Street, Suite B; Aloha, OR 97006
WHO WILL FOLLOW THIS NOTICE
This notice describes the information privacy practices followed by our employees,
staff and other office personnel.
YOUR HEALTH INFORMATION
This notice applies to the information and records we have about your
health, health status, and the health care and services you receive at
this office. Your health information may include information created
and received by this office, may be in the form of written or electronic
records or spoken words, and may include information about your health
history, health status, symptoms, examinations, test results, diagnoses,
treatments, procedures, prescriptions, related billing activity and
similar types of health-related information.
We are required by law to give you this notice. It will tell you about
the ways in which we may use and disclose health information about you
and describes your rights and our obligations regarding the use and
disclosure of that information.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
We may use and disclose health information for the following purposes:
� For Treatment. We may use health information about you to provide you
with medical treatment or services. We may disclose health information
about you to doctors, nurses, technicians, office staff or other
personnel who are involved in taking care of you and your health.
For example, your doctor may be treating you for a skin condition and
may need to know if you have other health problems that could complicate
your treatment. The doctor may use your medical history to decide what
treatment is best for you. The doctor may also tell another doctor
about your condition so that doctor can help determine the most
appropriate care for you.
Different personnel in our office may share information about you and
disclose information to people who do not work in our office in order to
coordinate your care, such as phoning in prescriptions to your
pharmacy, scheduling lab work and ordering x-rays. Family members and
other health care providers may be part of your medical care outside
this office and may require information about you that we have.
� For payment. We may use and disclose health information about you so
that the treatment and services you receive at this office may be billed
to and payment may be collected from you, an insurance company or a
For example, we may need to give your health plan information about a
service you received here so your health plan will pay us or reimburse
you for the service. We may also tell your health plan about a
treatment you are going to receive to obtain prior approval, or to
determine whether your plan will pay for the treatment.
� For Health Care Operations. We may use and disclose health
information about you in order to run the office and make sure that you
and our other patients receive quality care.
For example, we may use your health information to evaluate the
performance of our staff in caring for you. We may also use health
information about all or many of our patients to help us decide what
additional services we should offer, how we can become more efficient,
or whether certain new treatments are effective.
We may also disclose your health information to health plans that
provide you insurance coverage and other health care providers that care
for you. Our disclosures of your health information to plans and other
providers may be for the purpose of helping these plans and providers
provide or improve care, reduce cost, coordinate and manage health care
and services, train staff and comply with the law.
� Appointment Reminders. We may contact you as a reminder that you have
an appointment for treatment or medical care at the office.
� Treatment Alternatives. We may tell you about or recommend possible
treatment options or alternatives that may be of interest to you.
� Health-Related Products and Services. We may tell you about
health-related products or services that may be of interest to you.
Please notify us if you do not wish to be contacted for appointment
reminders, or if you do not wish to receive communications about
treatment alternatives or health-related products and services. If you
advise us in writing (at the address listed at the top of this Notice)
that you do not wish to receive such communications, we will not use or
disclose your information for these purposes.
We may use or disclose health information about you for the following
purposes, subject to all applicable legal requirements and limitations:
� To Avert a Serious Threat to Health or Safety. We may use and
disclose health information about you when necessary to prevent a
serious threat to your health and safety or the health and safety of the
public or another person.
� Required By Law. We will disclose health information about you when required to do so by federal, state or local law.
� Research. We may use and disclose health information about you for
research projects that are subject to a special approval process. We
will ask you for your permission if the researcher will have access to
your name, address or other information that reveals who you are, or
will be involved in your care at the office.
� Organ and Tissue Donation. If you are an organ donor, we may release
health information to organizations that handle organ procurement or
organ, eye or tissue transplantation or to an organ donation bank, as
necessary to facilitate such donation and transplantation.
� Military, Veterans, National Security and Intelligence. If you are or
were a member of the armed forces, or part of the national security or
intelligence communities, we may be required by military command or
other government authorities to release health information about you.
We may also release information about foreign military personnel to the
appropriate foreign military authority.
� Workers� Compensation. We may release health information about you
for workers� compensation or similar programs. These programs provide
benefits for work-related injuries or illness.
� Public Health Risks. We may disclose health information about you for
public health reasons in order to prevent or control disease, injury or
disability; or report births, deaths, suspected abuse or neglect,
non-accidental physical injuries, reactions to medications or problems
� Health Oversight Activities. We may disclose health information to a
health oversight agency for audits, investigations, inspections, or
licensing purposes. These disclosures may be necessary for certain
state and federal agencies to monitor the health care system, government
programs, and compliance with civil rights laws.
� Lawsuits and Disputes. If you are involved in a lawsuit or a dispute,
we may disclose health information about you in response to a court or
administrative order. Subject to all applicable legal requirements, we
may also disclose health information about you in response to a
� Law Enforcement. We may release health information if asked to do so
by a law enforcement official in response to a court order, subpoena,
warrant, summons or similar process, subject to all applicable legal
� Coroners, Medical Examiners and Funeral Directors. We may release
health information to a coroner or medical examiner. This may be
necessary, for example, to identify a deceased person or determine the
cause of death.
� Information Not Personally Identifiable. We may use or disclose
health information about you in a way that does not personally identify
you or reveal who you are.
� Family and Friends. We may disclose health information about you to
your family members or friends if we obtain your verbal agreement to do
so or if we give you an opportunity to object to such a disclosure and
you do not raise an objection. We may also disclose health information
to your family or friends if we can infer from the circumstances, based
on our professional judgment that you would not object. For example, we
may assume you agree to our disclosure of your personal health
information to your spouse when you bring your spouse with you into the
exam room during treatment or while treatment is discussed.
In situations where you are not capable of giving consent (because you
are not present or due to your incapacity or medical emergency), we may,
using our professional judgment, determine that a disclosure to your
family member or friend is in your best interest. In that situation, we
will disclose only health information relevant to the person�s
involvement in your care. We may also use our professional judgment and
experience to make reasonable inferences that it is in your best
interest to allow another person to act on your behalf to pick up, for
example, filled prescriptions, medical supplies, or Lab Reports.
OTHER USES AND DISCLOSURES OF HEALTH INFORMATION
We will not use or disclose your health information for any purpose
other than those identified in the previous sections without your
specific, written Authorization. If you give us Authorization to use
or disclose health information about you, 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.
In some instances, we may need specific, written authorization from you
in order to disclose certain types of specially-protected information
such as HIV, substance abuse, mental health, and genetic testing
YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU
You have the following rights regarding health information we maintain about you:
� Right to Inspect and Copy. You have the right to inspect and copy
your health information, such as medical and billing records, that we
keep and use to make decisions about your care. You must submit a
written request to Dr. Susan Denman in order to inspect and/or copy
records of your health information. If you request a copy of the
information, we may charge a fee for the costs of copying, mailing or
other associated supplies.
We may deny your request to inspect and/or copy records in certain
limited circumstances. If you are denied copies of or access to health
information that we keep about you, you may ask 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
� Right to Amend. If you believe health information we have about you
is incorrect or incomplete, you may ask us to amend the information.
You have the right to request an amendment as long as the information is
kept by this office.
To request an amendment, complete and submit a MEDICAL RECORD
AMENDMENT/CORRECTION FORM to Dr. Susan Denman. The MEDICAL RECORD
AMENDMENT/CORRECTION FORM is available from the Receptionist.
We may deny your request for an amendment if your request is not in
writing or does not include a reason to support the request. In
addition, we may deny your request if you ask us to amend information
� We did not create, unless the person or entity that created the information is no longer available to make the amendment
� Is not part of the health information that we keep
� You would not be permitted to inspect and copy
� Is accurate and complete
� Right to an Accounting of Disclosures. You have the right to request
an �accounting of disclosures.� This is a list of the disclosures we
made of medical information about you 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. To obtain this list, you must
submit your request in writing to Dr. Susan Denman. It must state a
time period, which may not be longer than six years and may not include
dates before April 14, 2003. Your request should indicate in what form
you want the list (for example, on paper, electronically). The first
list you request within a 12-month period will be free. For additional
lists, we may charge you for the costs of providing the list. We will
notify you of the cost involved and you may choose to withdraw or modify
your request at that time before any costs are incurred.
� Right to Request Restrictions. You have the right to request a
restriction or limitation on the health information 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 you
emergency treatment or we are required by law to use or disclose the
To request restrictions, you may complete and submit the REQUEST FOR
RESTRICTION ON USE/DISCLOSURE OF MEDICAL INFORMATION to Dr. Susan
Denman. The form is available from the Receptionist.
� Right to Request Confidential Communications. You have the right to
request that we communicate with you about medical matters in a certain
way or at a certain location. For example, you can ask that we only
contact you at work or by mail.
To request confidential communications, you may complete and submit the
REQUEST FOR RESTRICTION ON USE/DISCLOSURE OF MEDICAL INFORMATION AND/OR
CONFIDENTIAL COMMUNICATION to Dr. Susan Denman. The form is available
from the Receptionist. We will not ask you the reason for your request.
We will accommodate all reasonable requests. Your request must
specify how or where you wish to be contacted.
� Right to a Paper Copy of This Notice. You have the right to a paper
copy of this notice. You may ask us to give you a copy of this notice
at any time. Even if you have agreed to receive it electronically, you
are still entitled to a paper copy.
To obtain such a copy, contact the Receptionist.
CHANGES TO THIS NOTICE
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. We will post a
summary of the current notice in the office with its effective date in
the top right hand corner. You are entitled to a copy of the notice
currently in effect.
If you believe your privacy rights have been violated, you may file a
complaint with our office or with the Secretary of the Department of
Health and Human Services. To file a complaint with our office, contact
Dr. Susan Denman at the phone number/address given at the beginning of
this notice. You will not be penalized for filing a complaint.