Notice of Health Information Privacy Practices

Century Massage - Effective May 2007. Modified October 2016
​This notice describes how health information about you may be used or disclosed by our practice and how to access this
information. PLEASE REVIEW THIS NOTICE CAREFULLY. If you have any questions, please contact us at 425-228-5217.


The following categories describe different ways that we may use or disclose health information about you. Unless otherwise noted each of these uses and disclosures may be made without your permission. For each category of use or disclosure, we will explain what we mean and give some examples. Not every use or disclosure in a category will be listed. However, unless we ask for a separate authorization, all of the ways we are permitted to use and disclose information will fall within one of the categories.

For Treatment: We may use health information about you to provide you with healthcare treatment and services. We may
disclose health information about you to doctors, nurses, technicians, health students, volunteers or other personnel who are involved in taking care of you.

For Payment: We may use and disclose health information about you so that charges for treatment and services you receive from us may be billed to and payment collected from you, an insurance company, a state agency or other third party. For example, we may need to give your health insurance plan information about your office visit so your health plan will pay us or reimburse you for the visit. In some instances, we may need to tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

For Healthcare Operations: We may use and disclose health information about you for operations of our healthcare practice. These uses and disclosures are necessary to run our practice and make sure that all of our clients receive quality care. For example, we may use health information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine health information about many patients to decide what additional services we should offer, what services are not needed, whether certain new treatments are effective, or to compare how we are doing with others and to see where we can make improvements. We may remove information that identifies you from this set of health information so others may use it to study healthcare delivery without learning who our specific patients are.

Appointment Reminders: We may use and disclose health information to contact you as a reminder that you have an
appointment. Please let us know if you do not wish to have us contact you concerning your appointment, or if you wish to
have us use a different telephone number or address to contact you for this purpose.

As Required By Law: We will disclose health information about you when required to do so by federal, state, or local law; if asked to do so by a law enforcement official; or in response to court order, subpoena, warrant, summons or similar process.

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.

Health Oversight Activities: 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. These activities are necessary for the government 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 an order issued by a court or administrative tribunal. We may also disclose health information about you in
response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only after efforts have been made to tell you about the request and you have time to obtain an order protecting the information
requested. Such releases of information will be made only after efforts have been made to tell you about the request and
you have time to obtain an order protecting the information requested. 


You have the following rights regarding health information we maintain about you:

Right to Inspect and Copy: You have certain rights to inspect and copy health information that may be used to make
decisions about your care. Usually, this includes health and billing records. To inspect and copy health information that may be used to make decisions about you, you must submit your request in writing on a form, provided at the end of this notice. If you request a copy of your health information, we may charge a fee for the costs of locating, copying, mailing or other supplies and services associated with your request. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to health information, you may in certain instances request that the denial be reviewed. Another licensed healthcare professional chosen by our practice will review your request and the denial. The person conducting the review will not be the person who denied your initial request. We will comply with the outcome of the review.

Right to Amend: If you feel that 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 for as long as we keep the information. To request an amendment, your request must be made in writing on a form, provided at the end of this notice, and submitted to us. We may deny your request for an amendment if it is not the form provided by us and does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

- Was not created by us, unless the person or entity that created the information is no longer available to make the

- Is not part of the health information kept by or for our practice;

- Is not part of the information which you would be permitted to inspect and copy; or

- Is accurate or complete.

Any amendment we make to your health information will be disclosed to those with whom we disclose information as
previously specified.

Right to an Accounting of Disclosures: You have the right to request a list (accounting) of any disclosures of your health
information we have made, except for uses and disclosures for treatment, payment, and health care operations, as
previously described. To request this list of disclosures, you must submit your request on a form, provided at the end of this notice. Your request must state a time period that may not be longer than six years and may not include dates before April 14, 2003 [the compliance date of the Privacy Regulation]. The first list of disclosures 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. We will mail you a list of disclosures in paper form within 30 days of your request, or notify you if we are unable to supply the list within that time period and by what date we can supply the list; but this date should not exceed a total of 60 days from the date you made the request.

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 your care. For
example, you could ask that access to your health information be denied to a particular member of our practice who is known to you personally. While we will try to accommodate your request for restrictions, we are not required to do so if it is not feasible for us to ensure our compliance with law or we believe it will negatively impact the care we may provide you. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request a restriction, you must make your request on a form, provided at the end of this notice. In your request, you must tell us what information you want to limit and to whom you want the limits to apply.

Right to Request Confidential Communications: You have the right to request that we communicate with you about health matters in a certain manner or at a certain location. For example, you can ask that we only contact you at work or by mail to a post office box. During our intake process, we will ask you how you wish to receive communications about your health care or for any other instructions on notifying you about your health information. We will accommodate all reasonable requests.

Right to a Paper Copy of This Notice: You have the right to obtain a paper copy of this Notice at any time upon request. You may also obtain a copy of this Notice at our website at:
Minors and persons with guardians have all the rights outlined in this Notice with respect to health information relating to their healthcare.

We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for health
information we already have about you as well as any information we receive in the future. We will post a copy of the
current Notice in our office and on our website. The Notice contains the effective date on the first page.

If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health. You will not be penalized by our practice for filing a complaint. All complaints must be submitted in writing to: Washington State Department of Health, DOH HIPAA Privacy Official, P.O. Box 47890, Olympia, WA 98504-7890. For more information, call the DOH Consumer Assistance line at 800-525-0127.

Other uses and disclosures of health information not covered by this Notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization. We are unable to take back any disclosures we have already made with your permission, and we are required to retain the records of the care that we provided to you

Century Massage
& Bodywork, Inc.

Juice  Plus+ Representative

Contact: Marianne Valmonte

15 South Grady Way, Suite LL-25
Renton, WA 98057