This notice describes how medical information about your child may be used and disclosed, and how you can get access to this information. Please review it carefully.

This notice is considered a joint notice of an organized health care arrangement (OHCA) as it covers non-employee physicians from the Children’s University Medical Group as well as Boyer Children’s Clinic staff.

Boyer Children’s Clinic respects your privacy. We understand that your child and family’s personal health information is very sensitive. We will not disclose your information to others unless you tell us to do so, or unless the law authorizes or requires us to do so.

The law protects the privacy of the health information we create and obtain in providing our care and services to you and your child. For example, your child’s protected health information includes symptoms, test results, diagnoses, treatment, health information from other providers, and billing and payment information relating to these services. Federal and state law allows us to use and disclose your child’s protected health information for purposes of treatment and health care operations. State law requires us to get your authorization to disclose this information for payment purposes.

Entities covered in this notice include Boyer Children's Clinic and physicians providing medical services at Boyer Children's Clinic through contractual arrangement with the Children’s University Medical Group.  Entities participating in the OHCA will share patient information with each other as necessary to carry out treatment, payment, and health care operations relating to the OHCA


Examples of Use and Disclosures of Protected Health Information for Treatment, Payment, and Health Operations

For treatment:

  • Information obtained by a nurse, physician, or other member of our health care team will be recorded in your child’s medical record and used to help decide what care may be right for your child.
  • We may also provide information to others providing your child’s care. This will help them stay informed.

For payment:

  • We request payment from your health insurance plan and other third party payors.  Health plans and other payors need information from us about your child’s healthcare treatment at Boyer Children’s Clinic. Information provided to health plans and other third party payors may include your child’s diagnoses, procedures performed, progress, goals or recommended care.

For health care operations:

  • We use your child’s medical records to assess quality and improve services.
  • We may use and disclose medical records to review the qualifications and performance of our health care providers and to train our staff.
  • We may contact you to remind you about appointments and give you information about treatment alternatives or other health-related benefits and services.
  • We may contact you to raise funds.  Income from fund raising helps us provide quality care at Boyer Children’s Clinic.  We will include your family on our list of persons to receive information about fund raising efforts.  This information will only be used for the benefit of Boyer Children’s Clinic and not disseminated without your prior consent.
  • We may use and disclose your child’s information to conduct or arrange for services, including:
  • medical quality review by your health plan;
  • accounting, legal, risk management, and insurance services;
  • audit functions, including fraud and abuse detection and compliance programs.

For Business Associates:

  • We may disclose your personal information to our Business Associates, which are entities or individuals that are not employed by us that perform health care operations or payment activities on our behalf, which requires the collection, use or disclosure of your personal information.  We must have contracts with our business associates that require them to maintain the confidentiality of your personal information.  For example, we may contract with a healthcare billing service for our insurance billing.

Your Child’s Health Information Rights


The health and billing records we create and store are the property of Boyer Children’s Clinic. The protected health information in it, however, generally belongs to you. You have a right to:

  • Receive, read, and ask questions about this Notice;
  • Ask us to restrict certain uses and disclosures. You must deliver this request in writing to us. We are not required to grant the request, but we will review any request granted;
  • Request and receive from us a paper copy of the most current Notice of Privacy Practices for Protected Health Information (“Notice”);
  • Request that you be allowed to see and get a copy of your child’s protected health information created at Boyer Children’s Clinic.  This includes medical and billing records, other than psychotherapy notes.  In order to get a copy of this information, please make your request in writing to Boyer Children’s Clinic, 1850 Boyer Ave E, Seattle, WA 98112.
  • Ask us to change your child’s health information. You may give us this request in writing. You may write a statement of disagreement if your request is denied. It will be stored in your child’s medical record, and included with any release of your child’s records.
  • When you request in writing, we will give you a list of disclosures of your child’s health information. The list will not include disclosures to third-party payors. You may receive this information without charge once every 12 months. We will notify you of the cost involved if you request this information more than once in 12 months.
  • Ask that your health information be given to you by another means or at another location. Please sign, date, and give us your request in writing.
  • Cancel prior authorizations to use or disclose health information by giving us a written revocation. Your revocation does not affect information that has already been released. It also does not affect any action taken before we have it. Sometimes, you cannot cancel an authorization if its purpose was to obtain insurance reimbursement.


For help with these rights during normal business hours, please contact:
Mike Stewart   206-325-8477

Our Responsibilities


We are required to:

  • Keep your child’s protected health information private;
  • Give you this Notice;
  • Follow the terms of this Notice.
  • We have the right to change our practices regarding the protected health information we maintain. If we make changes, we will update this Notice. You may receive the most recent copy of this Notice by requesting one from the receptionist at Boyer Children’s Clinic during business hours.

To Ask for Help or Complain


If you have questions, want more information, or want to report a problem about the handling of your protected health information, you may contact:
Mike Stewart  206-325-8477

If you believe your privacy rights have been violated, you may discuss your concerns with any staff member. You may also deliver a written complaint to Mike Stewart, at Boyer Children’s Clinic. You may also file a complaint with the U.S. Secretary of Health and Human Services.

We respect your right to file a complaint with us or with the U.S. Secretary of Health and Human Services. If you complain, we will not retaliate against you.


Other Disclosures and Uses of Protected Health Information


Notification of Family and Others:

  • Unless you object, we may release health information about your child to a friend or family member who is involved in your child’s medical care.  We may also give information to someone who helps pay for your child’s care. We may tell your family or friends your child’s condition if they are sent to a hospital. In addition, we may disclose health information about you to assist in disaster relief efforts.

We may use and disclose your protected health information without your authorization as follows:


  • With Medical Researchers—if the research has been approved and has policies to protect the privacy of your health information. We may also allow researchers to review records while preparing to conduct a research project as long as they do not remove or make a copy of any Protected Health Information.
  • To Funeral Directors/Coroners consistent with applicable law to allow them to carry out their duties.
  • To Organ Procurement Organizations (tissue donation and transplant) or persons who obtain, store, or transplant organs.
  • To the Food and Drug Administration (FDA) relating to problems with food, supplements, and products.
  • To Comply With Workers’ Compensation Laws—if you make a workers’ compensation claim.
  • For Public Health and Safety Purposes as Allowed or Required by Law:
  • to prevent or reduce a serious, immediate threat to the health or safety of a person

or the public.

  • to public health or legal authorities
      • to protect public health and safety
      • to prevent or control disease, injury, or disability
      • to report vital statistics such as births or deaths.
  • To Report Suspected Abuse or Neglect to public authorities.
  • To Correctional Institutions if you are in jail or prison, as necessary for your health and the health and safety of others.
  • For Law Enforcement Purposes such as when we receive a subpoena, court order, or other legal process, or you are the victim of a crime.
  • For Health and Safety Oversight Activities. For example, we may share health information with the Department of Health.
  • For Disaster Relief Purposes. For example, we may share health information with disaster relief agencies to assist in notification of your condition to family or others.
  • For Work-Related Conditions That Could Affect Employee Health. For example, an employer may ask us to assess health risks on a job site.
  • To the Military Authorities of U.S. and Foreign Military Personnel. For example, the law may require us to provide information necessary to a military mission.
  • In the Course of Judicial/Administrative Proceedings at your request, or as directed by a subpoena or court order.
  • For Specialized Government Functions. For example, we may share information for national security purposes.

Other Uses and Disclosures of Protected Health Information


  • Uses and disclosures not in this Notice will be made only as allowed or required by law or with your written authorization.

Web Site


  • We have a Web site that provides information about us. For your benefit, this Notice is on the Web site at this address:

Changes to This Notice


We reserve the right to change this notice and make the new notice apply to Protected Health Information we already have as well as any we may receive after the notice is changed.  We will post a copy of our current notice in the Parent Room at Boyer Children’s Clinic.


The effective date of this Notice is April 14, 2003.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires us to ask each of our clients to acknowledge receipt of our Notice of Privacy Practices.  By my signature I acknowledge receipt of this Notice of Privacy Practices Statement for the child listed below.



Boyer Children's Clinic
1850 Boyer Children's Clinic
Seattle, WA  98112
(206) 325-8477
Fax: (206) 323-1385

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