Saint Helens Internal Medicine



I understand that Saint Helens Internal Medicine (referred to below as “This Practice”) will use and disclose private health information about me.

I understand that my private health information may include both created and received by the practice, may be in the form of written or electronic records or spoken words, and may include information about my health history, health status, symptoms, examinations, tests results, diagnoses, treatments, procedures, prescriptions and similar types of health-related information.

We are required by law to protect the privacy of your private medical information and to provide you with written Notice describing how private medical information about you may be used and disclosed and how you can access this information.

I understand and agree that This Practice may use and disclose my private health information in order to:

  • Refer to, consult with, coordinate among, and manage along with other health care providers for my care and treatment.
  • We may use or disclose to others your private medical information for purposes of providing or arranging for your health care with specialist, etc.  The payment for or reimbursement of the care that we provide to you, and the related administrative activities supporting your treatment.
  • We may be required or permitted by certain laws, regulations, or circumstances to use and disclose your private medical information for certain purposes without your authorization.  Under other circumstances we may need your written authorization (that you may later revoke) in order to use or disclose your private medical information.
  • As our patient, you have important rights relating to inspecting and copying your private medical information that we maintain, amending or correcting that information, obtaining an accounting of our disclosures of your private medical information, requesting that we communicate with you confidentially, requesting that we restrict certain uses and disclosures of your private health information, and complaining if you think your rights have been violated.
  • We have available a detailed NOTICE OF PRIVACY PRACTICES which fully explains your rights and our obligations under the law.  We may revise our NOTICE from time to time.  The Effective Date at the bottom right hand side of this page indicates the date of the most current NOTICE in effect.
  • You have the right to receive a copy of our most current NOTICE in effect.  If you have not yet received a copy of our current notice, please ask at the front desk and we will provide you with a copy.
  • If you have any questions, concerns or complaints about the NOTICE or your private medical information, please contact Rose Lockard - billing manager at 503-366-6244.


I also understand that this document serves as the written description of how This Practice will handle private health information about me.  This written description is known as a Notice of Privacy Practices and describes the uses and disclosures of private health information made and the information practices followed by the employees, staff and other office personnel of This Practice, and my rights regarding my private health information. 

I understand that the Notice of Privacy Practices may be revised from time to time, and that I am entitled to receive a copy of any revised Notice of Privacy Practices.

I understand that I have the right to ask that some or all of my private health information not be used or disclosed in the manner described in the Notice of Privacy Practices, and I understand that This Practice is not required by law to agree to such requests.

Revised 12-30-2013
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