Notice Privacy Practices

Rights And Responsibilities

Please Review Carefully

This notice describes your rights and responsibilities in how your medical information may be used and disclosed. Your provider will be happy to discuss this information with you.

Your Rights

When it comes to your health information, you have certain rights. Parents maintain these rights for their children aged 12 or younger. Adolescents who are aged 13-years or older maintain these rights for themselves.

You have the right to access your medical record
  • You may ask to see your medical record and/or get an electronic or paper copy of your medical record. Ask us how to do this so we can provide you with the appropriate forms.
  • At your request, we will provide you a copy of your health information, usually within 30 days of the request. We may charge a reasonable, cost-based fee.
You have the right to ask us to correct your medical record
  • You may ask us to correct any health information you think is incorrect or incomplete. Ask us how to do this.
  • We will notify you within 60 days if your request is accepted. If your request is not accepted, you will receive written documentation explaining the decision.
You have the right to request confidential communications
  • You may ask us to contact you in specific ways that protect your privacy such as identifying preferred contact information (home or office phone) or asking us to use a different mailing address.
  • We will accept all reasonable requests.
You have the right to ask us to limit what we use or share
  • You may ask us not to use or share certain health information for treatment, payment or our operations. We are not obligated to comply with this request and will be unable to do so if we believe it would affect your care.
  • If you pay for a service or health care item out-of-pocket, you may ask us not to share that information for the purpose of payment or our operations with your health insurer. We will comply unless a law requires us to share that information.
You have a right to get a list of those with whom we have shared information
  • You may ask for a list accounting the times we have shared your health information within a six-year period of time from the date of the request.
  • We will include all disclosures except for those about treatment, payment and health care operations or those which were requested by the client.
  • You will be provided one accounting per year free of charge. We will charge a reasonable, cost-based fee for any additional requests within that same 12-month period.
You have a right to receive a copy of this privacy notice
  • You may ask for a paper or electronic copy of this notice at any time and we will provide you with a copy of this information promptly.
You have the right to choose someone to act for you
  • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
  • Parents are able to make decisions for their child aged 12-years or younger.
You have a right to file a complaint if you feel your rights are violated
  • If you believe your rights have been violated you may file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights:
    Mailing Address: 200 Independence Ave SW, Washington D.C., 20201
    Phone: 877-696-6775
  • We will never retaliate against you for filing a complaint or voicing a concern
You have a right to make certain decisions about how we share your information
  • You may ask us to share information with family, friends or others involved in your care
  • You may choose to have us share your information in a disaster relief situation
  • You may choose whether we include your information in a hospital directory

Our Uses And Disclosures

We typically use or share your health information in the following ways:

  • To Best Treat You: We can share your information with other professionals who are treating you.
  • To Run Our Organization: We can use your information to run our practice, improve your care and contact you when needed.
  • To Bill For Services: We can share your information to bill and get payment from health plans or other entities.
  • Help With Public Health And Safety: If certain conditions are met, we may share health information about you to prevent disease, help with product recall, report adverse reactions to medications or participate in health research.
  • Safety: We will share your information to report suspected abuse, neglect or domestic violence. We will share your information to prevent or reduce serious threat to anyone’s health or safety.
  • Comply With The Law: We will share information about you if mandated by state or federal law. We can share health information about you in response to a court or administrative order or in response to a subpoena.
  • Work With a Medical Examiner: We can share health information with a coroner, medical examiner or funeral director after an individual dies.

Our Responsibilities

We are required by law to maintain the privacy and security of your protected health information.

  • We will not use or share your information other than as described here unless you provide written permission. You may revoke this permission at any time by notifying us in writing.
  • We must follow the duties and privacy practices described in this notice and provide you with a copy. You may also request a copy of this notice at any time.
  • We will let you know promptly if a breach occurs that may compromise the privacy or security of your information.
  • For more information visit:

Changes To The Terms Of This Notice

We reserve the right to change the terms of this notice. Any changes will apply to all information we have about you. Any changes will be discussed with you. The new notice will be available upon request, in our office and on our website.

Effective Date

This notice is effective as of September 1, 2023.

Children's Behavioral Medicine Collaborative, PLLC
2412 North 30th St
Suite 201
Tacoma, WA 98407
United States
Phone: (253) 256 3626
Fax: (253) 256 3786
[email protected]