• 3876 Bridge Way N, #300, Seattle, WA 98103


  • (206) 257-4022


NOTIFICATION OF PRIVACY PRACTICES Natural Rhythms Integrative Medicine         Rev 4/3/2017


TREATMENT – Your health information may be used by our providers and staff members or may be disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment.

PAYMENT – Your health information may be used to seek payment from your health plan, other sources of coverage such an automobile insurer, or credit card companies that you may use to pay for services. For example, your health plan may request and receive information on dates of service, the services provided, and the medical condition being treated.

HEALTH CARE OPERATIONS – Your health information may be used as necessary to support the day-to-day activities and management of NRIM. For example, information on the services you received may be used to support budgeting and financial reporting and activities to evaluate and promote quality to ensure that our practice is meeting state and federal guidelines and laws designated to protect your health care information.

LAW ENFORCEMENT – Your health information may be disclosed to law enforcement agencies, without your permission, to support government audits and inspections, to facilitate law enforcement investigations, and to comply with government mandated reporting.  For example, any known or reasonably suspected cases of child abuse or neglect, any known or suspected intentions of harming oneself (suicide), and/or any known or suspected intentions of harming others.

PUBLIC HEALTH REPORTING – Your health information may be disclosed to public health agencies as required by law. For example, our practice is required to report certain communicable diseases to the State of Washington Department of Health.

BUSINESS ASSOCIATES – The following companies may have access to your Protected Health Information for the purpose of carrying out Treatment, Payment, and/or Health Care Operations:  Prestige Medical Billing Company, Inc., Samantha Czapiewski – office manager.

OTHER USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION – Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a disclosure or use of your information, you may submit a written revocation of the authorization. However, your decision to revoke your authorization will not affect or undo any disclosure or use that occurred before you notified this practice of your decision.

INFORMATION ABOUT TREATMENT – Your health information may be used to send you information on the treatment and management of your health condition that you may find of interest. We may also send you information describing other health-related goods and services that we believe may interest you.


The right to request restrictions on the disclosure and use of your protected health information; The right to receive confidential communications concerning your medical condition and treatment; The right to inspect and copy your protected health information; The right to request an amendment or to submit corrections to your protected health information; The right to receive an accounting of how and to whom your protected health information has been disclosed; The right to receive a printed copy of this notice.

PROVIDER / OFFICE DUTIES – We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices. We are also required to abide by the privacy policies and practices that are outlined in this notice.

RIGHT TO REVISE PRIVACY PRACTICES – As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. Whatever the reason for these revisions, we will provide you with a revised notice at your next office visit. These revised policies and practices will be applied to all protected health information we maintain.

RIGHT TO INSPECT PROTECTED HEALTH INFORMATION – As permitted by federal regulation, we require that requests to inspect or copy protected health information be submitted in writing. You may obtain a form to request access to your records by contacting your individual practitioner or the front office.  If you request a copy of your records, the following fees will be assessed: $24 Clerical fee, $1.09 per page fee for the first 30 pages and then $0.82 per page for any pages 31 and over.  This fee must be paid prior to the copies being released.

COMPLAINTS AND CONTACT PERSON – If you would like to submit a comment or complaint about our privacy practices or obtain additional information about our privacy practices, you can do so by sending a letter outlining your concerns to the person listed below. You will not be penalized or otherwise retaliated against for filing a complaint.

Natural Rhythms Integrative Medicine 3876 Bridge Way North ste 300 Seattle, WA 98103

OR YOU MAY ALSO CONTACT: Office for Civil Rights-U.S. Dept of Health and Human Services

701 Fifth Avenue, Suite 1600, MS – 11, Seattle, WA 98104                Voice Phone (800) 368-1019     FAX (206) 615-2297

Please sign to acknowledge receipt of our Privacy Policy.*

Signature:                                                                                                                                 Date: