Notice of Privacy Practices
Effective Date: October 1, 2026
This Notice describes how medical and dental information about you may be used and disclosed, how you can obtain access to that information, and your privacy rights. Please review it carefully.
Download PDFThis Notice applies to Roosevelt Oral Surgery. We are required by law to protect the privacy and security of your protected health information, provide you with this Notice, and follow the privacy practices described in the Notice currently in effect.
Your Rights
Access your health information
You may ask to inspect or receive an electronic or paper copy of the health information we maintain about you. We will respond within the time required by applicable law. Washington law generally requires a provider to act on a written request to inspect or copy records no later than 15 working days after receipt, subject to limited extensions and lawful grounds for denial. We may charge a reasonable fee when permitted by law.
Ask us to correct or amend your record
You may ask us in writing to correct or amend health information that you believe is inaccurate or incomplete. We may deny a request in circumstances permitted by law, but we will explain the decision and any right you have to submit a statement of disagreement. Washington law generally requires action on a correction or amendment request within 10 days, subject to limited extensions.
Request confidential communications
You may ask us to contact you in a particular way or at a particular location. We will accommodate reasonable requests as required by law.
Ask us to limit certain uses or disclosures
You may ask us not to use or disclose certain health information for treatment, payment, or health care operations. We are generally not required to agree. If you pay in full out-of-pocket for a health care item or service, however, you may ask us not to disclose information about that item or service to your health plan for payment or health care operations, and we will honor the request unless disclosure is required by law.
Receive an accounting of certain disclosures
You may request an accounting of certain disclosures of your health information made during the six years before your request. The accounting does not include every disclosure, including many disclosures for treatment, payment, health care operations, disclosures to you, and disclosures you authorized. We will provide one accounting in a 12-month period without charge and may charge a reasonable, cost-based fee for additional accountings as permitted by law.
Receive a copy of this Notice
You may request a paper copy of this Notice at any time, even if you previously agreed to receive it electronically.
Choose someone to act for you
A person who is legally authorized to act as your personal representative may exercise your privacy rights to the extent permitted by law. We may verify that person's authority before acting on a request.
File a complaint
If you believe your privacy rights have been violated, you may complain to Roosevelt Oral Surgery using the contact information at the end of this Notice. You may also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you for exercising your rights or filing a complaint.
Your Choices
Family, friends, and others involved in your care
You may tell us your preferences about sharing information with family members, close friends, caregivers, or others involved in your care or payment for your care, and about disclosures made for disaster-relief purposes. If you are unable to tell us your preference, we may use professional judgment and applicable law to determine whether a limited disclosure is in your best interest.
Uses that generally require written authorization
We generally will obtain your written authorization before using or disclosing your health information for marketing, selling your health information, or most uses or disclosures of psychotherapy notes when applicable. If you give us a written authorization, you generally may revoke it in writing at any time, except to the extent we have already acted in reliance on it.
How We May Use and Share Your Health Information
Treatment
We may use and disclose your health information to provide, coordinate, or manage your care. For example, we may share relevant information with your referring dentist, restorative dentist, physician, pharmacy, laboratory, imaging facility, hospital, anesthesia provider, or another health professional involved in your care.
Payment
We may use and disclose health information to bill and obtain payment from you, a dental or medical benefit plan, or another person or entity responsible for payment.
Health care operations
We may use and disclose health information to operate our practice and support activities such as quality improvement, staff training, credentialing, compliance, auditing, legal and accounting services, information technology, and other health care operations permitted by law.
Appointment and care communications
We may contact you about appointments, treatment, follow-up care, prescriptions, preoperative or postoperative instructions, and other matters related to your care using appropriate communication methods and subject to applicable law and your communication preferences.
Business associates
We may share health information with vendors and service providers that perform functions for us when permitted by law. When required, these business associates must agree to appropriately safeguard protected health information.
Other permitted or required disclosures
We may use or disclose health information without your written authorization when permitted or required by law, including for certain public-health and safety activities; reports of abuse, neglect, or domestic violence; health oversight; workers' compensation; certain law-enforcement and governmental functions; qualifying judicial or administrative proceedings; organ and tissue donation; coroners, medical examiners, and funeral directors; certain research activities; prevention or reduction of a serious and imminent threat; and other disclosures required by law. We will apply the conditions and limitations imposed by federal and Washington law before making such disclosures.
Additional Protections Under Federal and Washington Law
Washington health information law
Washington's health information law, Chapter 70.02 RCW, provides privacy, access, amendment, authorization, and disclosure protections that may be more protective than federal law in particular circumstances. When Washington law provides greater protection or a stronger patient right than HIPAA, we will follow the more protective applicable requirement.
Sexually transmitted disease information
Washington law places additional limits on disclosure of information and records related to sexually transmitted diseases. We will disclose this information only as permitted or required by applicable law and will use any redisclosure notice required by Washington law.
Mental health information
Information and records related to mental health services may be subject to additional confidentiality restrictions under Washington law. We will not disclose specially protected mental health information except as permitted or required by applicable law.
Minors
Washington law may allow a minor to consent to certain categories of health care without parental consent. When a minor lawfully consents to care on the minor's own behalf, Washington law may give the minor control over privacy rights for information related to that care. We will follow the applicable consent and confidentiality rules for the particular service and circumstances.
Substance use disorder records
To the extent we receive or maintain substance use disorder patient records protected by 42 CFR Part 2, additional federal protections apply. We will not use or disclose Part 2 records in a civil, criminal, administrative, or legislative investigation or proceeding against the patient unless the patient provides the required written consent or the disclosure is authorized by a qualifying court order and subpoena as required by law.
Protected health care services
Washington law provides additional protections relating to certain protected health care services that are lawful in Washington, including reproductive health care and gender-affirming treatment. We will comply with applicable Washington restrictions on responding to out-of-state investigations, subpoenas, or proceedings involving such lawful care.
Our Responsibilities
Protect your information
We are required by law to maintain the privacy and security of protected health information and to comply with applicable federal and Washington privacy requirements.
Breach notification
We will notify affected individuals as required by law if a breach occurs that compromises the privacy or security of protected health information.
Follow this Notice
We must follow the duties and privacy practices described in the Notice currently in effect. We will not use or disclose your health information other than as described here unless you authorize us in writing or another use or disclosure is permitted or required by law.
Changes to This Notice
Changes
We may change the terms of this Notice and our privacy practices as permitted by law. A revised Notice may apply to all health information we maintain, including information created or received before the revision. The current Notice will be available at our office, upon request, and on our website.
Questions, Requests, or Complaints
Privacy contact
To exercise your privacy rights, request a copy of this Notice, ask a privacy question, or make a complaint, contact:Privacy Officer
Michael Siew
Roosevelt Oral Surgery
916 NE Ravenna Blvd, Suite A
Seattle, WA 98115
Phone: (206) 845-7333
Email: [email protected]
You may also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights. Information about filing a complaint is available at HHS.gov. Roosevelt Oral Surgery will not retaliate against you for filing a complaint.