For Examinees: Privacy Practices: HIPAA

(Our Privacy Practices are also available as a downloadable PDF. To download this form, please click here.)

JOINT NOTICE OF PRIVACY PRACTICES

Effective Date of Notice: March 1, 2007

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

This Joint Notice of Privacy Practices ("Notice") describes the privacy practices of:
1. The Central Seattle Panel of Consultants, Inc.
2. Central Seattle Panel of Consultants
3. Everett Panel of Consultants
4. Panel of Consultants
5. All physicians and staff members while providing services at or through CSPC
6. All CSPC employees (including employed physicians), and other personnel and workforce members.
"We," "us," "our" and "CSPC" in this Notice refer to the parties listed above. This Notice does not cover the health information collected, created, and maintained by, through, or at independent providers outside CSPC. This Notice covers only the health information collected, created, and maintained by, through, or at CSPC.

If you have any questions, please contact the CSPC Privacy Officer listed at the end of this Notice.

II.
WHO WE ARE
We are an organization of independent contractor physicians with private practices of their own, who perform evaluations of industrial and other injuries. Our physicians will evaluate the residual effects of your injury and make whatever recommendations are appropriate from their findings. This affords another opinion regarding your injury and may suggest other treatment possibilities. Our physicians have private practices but have agreed to participate in panel examinations to bring their extensive experience to the evaluation of your injury or condition.

Our physicians provide evaluation of your injury or condition, but do not provide or recommend treatment of your injury or condition. It is necessary for your attending doctor to discuss with you and direct your medical treatment, if any.

By the very nature of our services, we will be disclosing your health information to third parties, most commonly the workers' compensation administrator (in Washington, the Department of Labor and Industries), self-insured employers or private insurance companies. Disclosures to the workers' compensation administrator and self-insured employers are permitted by law. For other third parties we will secure your authorization for this disclosure in advance of your evaluation.

III.
USE AND DISCLOSURE OF YOUR HEALTH INFORMATION
Prior to your evaluation, we ordinarily receive a copy of your relevant medical records from the workers' compensation administrator, a private insurance company, or a lawyer requesting the evaluation. We then create a report of your evaluation. We need this report to provide you and those requesting the evaluation with the results of our evaluation of your injury or condition and to comply with certain legal requirements. Your ability to get a copy of the report is discussed below. We understand that your health information is personal, and we are committed to protecting health information about you. For many of the situations described below, we will use, disclose, or receive the minimum amount of health care information necessary to accomplish the intended purpose.

The following categories describe different ways we use and disclose health information and give some examples of the way we use and disclose health information. Not every use or disclosure in a category will be listed. But, the ways we are permitted to use and disclose information will fall within one of the categories.

A. Use and Disclosure of Your Health Information for "Treatment," Payment, and Operations:

Treatment: As discussed above, our physicians do not provide you with "treatment" in the ordinary sense, but rather provide an independent evaluation of your injury or condition. We use "treatment" in this Notice to refer to our evaluations and will comply with all privacy laws related to use of information for such "treatment."

We may use health information about you to give you "treatment," coordinate, and manage "treatment" or other services. We may disclose health information about you to doctors, nurses, technicians, or other personnel who are involved in evaluating you at or through CSPC. To assist with your care outside CSPC, we may disclose your health information to your doctor or other health care providers who are not employed by or subcontractors of CSPC. For example, we may provide your health information to a doctor who is seeing you in his or her office.

Payment: We may use and disclose your health information to bill and collect payment from others for the services you received. We also may share your information with other providers who are involved in your "treatment" for their payment purposes.
Health Care Operations: We may use and disclose health information about you for our operations. These uses and disclosures are needed to run our facilities and allow our patients to receive quality evaluations. We may combine information about many patients to determine the need for new services or treatment. We may disclose health information to health care professionals for educational purposes. We may disclose your health information to other health care providers or to health plans for their own health care operations as long as they have or had a relationship with you, the information is about that relationship, and the information is used for only certain purposes.

Appointment Reminders: We may use and disclose health information to remind you that you have an appointment with us.

B. Uses and Disclosures That We May Make Unless You Object:
Individuals Involved in Your Evaluation or Payment for Your Evaluation or Notification: Unless you object, we may disclose some of your health information to a family member, close personal friend, or any other person you identify who is involved in your evaluation or payment for your evaluation. Except in certain limited situations, such as an emergency, or if you are not able to communicate, we will ask you and determine if you object. We may disclose: health information that is needed for that person's involvement in your treatment or payment related to your treatment; or health information to find and tell those close to you of your location or condition. If you are not present or unable to tell us your preference, we may, in our professional judgment, disclose health information in your best interests to the extent that the information is relevant to the person's involvement in your treatment. We may use professional judgment and experience when allowing a person to pick up prescriptions, medical supplies, x-rays, or other similar forms of health information on your behalf.

In the Event of a Disaster: We may disclose health information about you to an entity assisting in a disaster relief effort to coordinate care and so that your family can be notified about your condition and location.

C. Uses and Disclosures We May Make Without Your Authorization:
Workers' Compensation: We are required by law to disclose health information to the workers' compensation administrator or self-insured employer for workers' compensation or crime victims' claims and may make such disclosures without your authorization. We also may disclose health information to an employer about light duty work, a workplace injury or illness, a workplace medical surveillance, or a return-to-work examination without an authorization from you. Your ability to object to disclosure or access your information related to workers' compensation is governed by the workers' compensation laws.

As Required by Law: We will disclose health information about you when required to do so by federal, state, or local law.

Business Associates: We may disclose health information to those that we contract with as business associates so that they may perform services on our behalf. Examples include translator and transcription services.

Public Health Activities: We may disclose your health information for public health activities. These activities generally include disclosures:
• To a public health authority authorized by law to collect information to prevent or control disease, injury, or disability, such as the reporting of disease, injury, vital events (births, deaths, etc.) or for public health surveillance, investigations, and interventions
• To a public health authority or other agency authorized by law to receive reports of actual or suspected child abuse or neglect
• To a person responsible for federal Food and Drug Administration ("FDA") activities for purposes related to the quality, safety, or effectiveness of FDA-regulated products or activities
• To a person who may have been exposed to a communicable disease or may be at risk for contracting or spreading a disease or condition, as authorized by law
• To an employer about an individual who works for the employer, in certain situations, such as to conduct medical surveillance of the workplace or to evaluate whether an individual has a work-related illness or injury.

Victims of Abuse, Neglect, or Domestic Violence: We may disclose health information about an individual we reasonably believe to be the victim of abuse, neglect, or domestic violence to a government authority authorized by law to receive such reports. We will make this disclosure if you agree to the disclosures. We also will make this disclosure if the disclosure is required by law. If the disclosure is allowed by law, then we will disclose information as long as we believe the disclosure is necessary to prevent harm to the individual or other potential victims. Also, if an individual is incapacitated, we may disclose information to a person authorized to receive such reports, if that person represents that the health information is not intended to be used against the individual and immediate enforcement activity depends upon the disclosure.

Health Oversight: We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure.

Lawsuits and Disputes: We may disclose health information about you in response to a court or administrative order. We also may disclose health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in a dispute, but only if the requesting party states that it has made efforts to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement Activities: We may disclose health information if asked to do so by a law enforcement official: as required by law that requires reporting of certain types of wounds; in response to court orders, subpoenas, warrants, summons, grand jury subpoenas, certain administrative requests, or similar processes; to identify or locate a suspect, fugitive, material witness, or missing person (but we will give only limited information); about the victim of a crime in certain circumstances; about a death we suspect may be the result of criminal conduct; about criminal conduct on our premises; and in emergencies, to report a crime, the location of the crime or victims, or the identity, description, or location of the person who committed the crime.

Coroners, Medical Examiners, and Funeral Directors: We may release health information to a medical examiner or coroner as necessary, or required, to identify a deceased person or determine the cause of death. We also may release health information about individuals to funeral directors so they can perform their duties.

Organ and Tissue Donations: We may disclose health information to organizations that handle organ procurement or organ, eye, or tissue transplants or to an organ donation bank, as required and needed for organ or tissue donation and transplants.

Research: Under certain circumstances, we may use and disclose health information about you for research purposes. We may use or disclose your health information to prepare for a research project. Most of the time, we will ask for your authorization before using or disclosing your information for research.

To Avert a Serious Threat to Health or Safety: We may use and disclose your health information when we reasonably believe it is necessary to prevent a serious threat to the health and safety of you, the public, or another person. The disclosure would only be to someone who is likely to help prevent the threat.

National Security and Intelligence Activities: We may disclose health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Protective Services for the President and Others: We may disclose health information about you to authorized federal officials so they may protect the President, other authorized persons, or foreign heads of state or may conduct special investigations.

Military Personnel: If you are a member of the armed forces, we may release health information about you as required by your military command authorities.
Inmates: If you are an inmate of a correctional institution or under custody of a law enforcement official, then we may release health information about you to the correctional institution or a law enforcement official.

Organized Health Care Arrangement: CSPC and its subcontractor physicians participate in an arrangement called an "organized health care arrangement" solely to comply with federal privacy regulations and have agreed to follow this Notice for services given to you by or at CSPC. These providers may share health information with each other as needed for treatment, payment, and the health care operations of the organized health care arrangement and as described in this Notice. But, CSPC is not responsible for actions by independent medical staff.
Incidental Disclosures: Certain incidental disclosures of your health information may occur as a by-product of permitted uses and disclosures.
Limited Data Sets: We may disclose limited health information, contained in a "limited data set," to certain third parties for research, public health, and health care operations. Before disclosing limited data sets, we will enter into an agreement with the recipient that limits the recipient's use and disclosure of this information and prohibits the recipient from attempting to re-identify the data or from contacting you.
De-identified Information: We may use and disclose health information that reasonably has been "de-identified" by removing certain identifiers (such as name and address) making it unlikely that you could be identified.

Personal Representatives: Certain minors and incapacitated adults may have "personal representatives." These personal representatives may be able to act on the person's behalf, access the person's health information, and exercise the person's privacy rights.

D. Uses and Disclosures with Authorization:
Your Authorization: Other uses and disclosures of your health information not covered by this Notice or the laws that apply to us will be made only with your written permission or authorization. If you give us an authorization to use and disclose your health information, then you may revoke your authorization, in writing, at any time (unless you are told otherwise at the time you sign the authorization). If you revoke your authorization, then we will no longer use or disclose your health information for the reasons covered by your written authorization, except to the extent that we already have relied on your authorization. We are unable to take back any disclosures we have already made with your permission and that we are required to retain our records of the care that we provided to you.

Specially Protected Health Information: Unless otherwise required or permitted under law, we may need to obtain your specific authorization for disclosure of the following health information:
• Positive AIDS/HIV/ARC information
• Mental health and mental illness records
• Drug addiction, alcoholism, and other substance abuse treatment records
• Developmental disabilities records
• Genetic information.
The first four items of the above information are routinely requested and disclosed via our authorization.

IV.
YOUR HEALTH INFORMATION RIGHTS
NOTE FOR WORKERS' COMPENSATION PATIENTS:
THE FOLLOWING ACCESS AND AMENDMENT RIGHTS MAY BE
LIMITED BY THE WORKERS' COMPENSATION LAWS OF THE
STATE IN WHICH YOUR INJURY OCCURRED.

Although your health record is our property, you have the rights described below with respect to your health information:
Right to Inspect and Copy: You have the right to inspect and obtain copies of health information that may be used to make decisions about your care. To inspect or obtain a copy of your health information, you must submit your request to your claims adjudicator.
We will provide a copy of our evaluation report to the ordering party and you will be required to seek a copy from such party in accordance with applicable law.

Right to Amend: If you feel that health information we have about you is incorrect or incomplete, then you have the right to request a reasonable amendment. To request an amendment, you must submit your request to your claims adjudicator.

Right to an Accounting of Disclosures: You have the right to request an accounting of certain disclosures of your health information. This accounting will not include disclosures:
• For treatment, payment, or health care operations
• To you under your right of access to your records
• That you authorized
• To persons involved in your care, or for notification purposes
• Incidental to an otherwise permitted use or disclosure
• As part of a limited data set
• For national security or intelligence purposes
• To correctional institutions or other custodial law enforcement officials or
• That occurred before April 14, 2003.

To request this list or accounting, you must submit your request in writing to our Privacy Officer.

Right to Request Restrictions: You have the right to request a restriction or limitation on the health information we use 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 of your care. To request a restriction, you must submit your request in writing to our Privacy Officer. 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 with emergency treatment.

Right to Request Confidential Communications: You have the right to request that we communicate with you about health matters in a certain way or at a certain location. To request confidential communications regarding your health information, you must submit your request in writing to our Privacy Officer. We will agree to the request if it is reasonable for us to do so.
Right to a Copy of this Notice: You have the right to receive a written copy of this Notice. This applies even if you agreed to receive this Notice electronically. Copies of the Notice are available from the front desk. You also may access our website at www.panelofconsultants.com to request a copy of this Notice.

Releasing Reports in Workers Compensation Cases: If your examination is at the request of the workers' compensation administrator or self-insured employers, the release of reports, including release to you, will be governed by the applicable workers' compensation laws. Ordinarily, the examining physician will direct pre-examination communications to the worker's claim(s) administrator. He or she will disclose the findings of the examination with an appropriate release form, but only after the report has been submitted to the workers' compensation administrator of self-insurer. If you desire a copy of the report, we ask that you direct your request to your treating physician or your claims administrator.

V.
ACCOMPANIMENT DURING EXAMS
If you are scheduled for an examination requested by L&I or self-insured employers, you are allowed to bring with you an accompanying person to be present during the examination, such as a friend or family member. You may not be accompanied during psychiatric examinations. The accompanying person's role is to provide comfort and reassurance to you during the examination and must quietly observe the examination, cooperate with the examiner and must not interfere.
The accompanying person may not be compensated in any manner, except that language interpreters may be necessary for the communication process and may be reimbursed for interpretive services if authorized by the department. This means attorneys, attorneys' staff, doctors, doctors' staff, employers, employers' representatives, and paid witnesses may not attend. Minor children also may not accompany you to the examination. However, a union representative may attend as a friend. We encourage you to notify the examiner's office at least two working days prior to the date of the examination if someone will accompany you during the examination.
When an examination is requested by other parties-such as the Board of Industrial Insurance Appeals, insurance companies or attorneys-other laws may apply.

VI.
OUR RESPONSIBILITIES REGARDING YOUR HEALTH INFORMATION
We are required by law to:
• Maintain the privacy of your health information
• Give you this Notice of our legal duties and privacy practices with respect to the information we collect and maintain about you and
• Follow the terms of the Notice that is currently in effect.

PLEASE NOTE: Auditory privacy is not guaranteed.

VII.
CHANGES TO THIS NOTICE
We will give you a copy of our Notice the first time you register for services at CSPC. We reserve the right to change this Notice. The revised Notice will be effective for information we already have about you as well as any information we receive in the future. Unless required by law, the revised Notice will be effective on the new effective date of the Notice. The current Notice will be available in our registration areas or on our website. The Notice will contain an effective date.

VIII.
COMPLAINTS
If you believe that your privacy rights have been violated, you may file a complaint with the Privacy Officer by mailing your concerns to:
Panel of Consultants
Attention: Privacy Officer
411 12th Avenue Suite 300
Seattle, Washington 98122-5523

If your examination is at the request of the workers' compensation administrator or self-insured employers, the filing of a complaint will be governed by the applicable workers' compensation laws and should be made to your claims administrator. You will not be penalized for filing a complaint.