Notice of Privacy Practices

In this notice, “you” means the patient. For most of our patients, that means a child, and a parent or guardian exercises these rights on the child’s behalf. See A note for parents and teens.

Your rights

When it comes to your health information, you have certain rights. This section explains them and some of our responsibilities to help you.

Get a copy of your medical record

You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how. We will provide a copy or a summary, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

You can ask us to correct health information that you think is incorrect or incomplete. We may say “no” to your request, but we will tell you why in writing within 60 days.

Request confidential communications

You can ask us to contact you in a specific way, for example on a mobile rather than a home phone, or to send mail to a different address. We will say “yes” to all reasonable requests.

Ask us to limit what we use or share

You can ask us not to use or share certain health information for treatment, payment or our operations. We are not required to agree, and we may say “no” if it would affect your care. If you pay for a service or item out of pocket in full, you can ask us not to share that information with your health insurer for payment or our operations. We will say “yes” unless a law requires us to share it.

Get a list of those with whom we have shared information

You can ask for a list, an accounting, of the times we have shared your health information in the six years before your request, who we shared it with, and why. It will include all disclosures except those about treatment, payment and health care operations, and certain others, such as any you asked us to make. We provide one accounting a year free, and charge a reasonable, cost-based fee if you ask for another within 12 months.

Get a copy of this notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive it electronically. We will provide it promptly.

Choose someone to act for you

If you have given someone medical power of attorney, or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority before we act.

File a complaint if you feel your rights are violated

You can complain to us using the contact details at the end of this notice, or to the U.S. Department of Health and Human Services Office for Civil Rights. We will not retaliate against you for filing a complaint.

A note for parents and teens

A parent or legal guardian usually acts for a child and can exercise the rights in this notice. There are exceptions. Oregon law lets young people consent to some care on their own: most medical care from age 15, outpatient mental health and substance use treatment from 14, and birth control and testing and treatment for sexually transmitted infections at any age. When a teen consents to their own care, the teen may control the information about it, and we may need their permission to share it with a parent. We encourage teens to involve their parents, and we explain these limits to both at the first teen visit. Teen checkups and confidential care.

Your choices

For certain health information, you can tell us your choices about what we share. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and the choice to tell us to:

• Share information with family, close friends or others involved in your care
• Share information in a disaster relief situation

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share it when needed to lessen a serious and imminent threat to health or safety.

In these cases, we never share your information unless you give us written permission:

• Marketing purposes
• Sale of your information
• Most sharing of psychotherapy notes

We do not fundraise, so we will never contact you for that purpose.

Our uses and disclosures

Treat you

We can use your health information and share it with other professionals who are treating you. Example: a specialist treating your child’s asthma asks us about their growth and vaccines.

Run our practice

We can use and share your health information to run our practice, improve your care and contact you when necessary. Example: we use it to send appointment reminders and to review the quality of our care.

Bill for your services

We can use and share your health information to bill and get payment from health plans or other entities. Example: we give information about a visit to your child’s health plan so it will pay for it.

How else we can use or share your health information

We are allowed or required to share your information in other ways, usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share it for these purposes.

Help with public health and safety issues

• Recording every vaccine in ALERT IIS, Oregon’s immunization registry
• Giving proof of immunization to a school or child care provider that requires it, with your agreement
• Reporting certain diseases, as public health law requires
• Reporting suspected abuse or neglect of a child, as Oregon law requires of every health care provider
• Helping with product recalls and reporting adverse reactions to medicines and vaccines
• Preventing or reducing a serious threat to anyone’s health or safety

Do research

We can use or share your information for health research, under the conditions the law sets.

Comply with the law

We will share information about you if state or federal law requires it, including with the Department of Health and Human Services if it wants to see that we are complying with federal privacy law.

Respond to organ and tissue donation requests

We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director

We can share health information with a coroner, medical examiner or funeral director when an individual dies.

Address workers’ compensation, law enforcement and other government requests

• For workers’ compensation claims
• For law enforcement purposes or with a law enforcement official
• With health oversight agencies for activities authorized by law
• For special government functions such as military, national security and presidential protective services

Respond to lawsuits and legal actions

We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Our responsibilities

• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

Changes to the terms of this notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available on request, in our office and on this website.

Questions and complaints

For questions about this notice, or to exercise any of these rights, contact our Privacy Officer, the practice manager:

Sagebrook Pediatrics, 1174 NW Wall Street, Suite 200, Bend, OR 97703
Phone (541) 555-0148 (TTY: 711) · Fax (541) 555-0149
Email hello@sagebrookpeds.com

You can file a complaint with the Office for Civil Rights:

U.S. Department of Health and Human Services, Office for Civil Rights
200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201
Phone 1-800-368-1019 · TDD 1-800-537-7697
Online: the OCR Complaint Portal

Effective date of this notice: September 30, 2026.