Trillium Family Services
Notice of Privacy Practices
Recognizing that certain information you provide to us is confidential, Trillium Family Services has adopted
formal policies regarding access to confidential medical information. The following notice describes how your
protected health information (PHI) may be used and disclosed, and how you can get access to this information.
Please read both sides of this notice carefully.
I. Uses and Disclosures That Do Not Require Written Authorization
In certain situations, we will not require your written authorization in order to use and disclose your protected
health information. These situations include:
- Treatment, Payment and Health Care Operations. We may use and disclose PHI, in order to treat you, obtain payment for services provided to you and conduct our health care operations.
- Public Health Activities. We may disclose your PHI for the following public health activities: (1) to report
health information to public health authorities for the purpose of preventing or controlling disease, injury or
disability; (2) to report victims of domestic violence, child abuse or neglect to the Oregon Department of Human
Services; (3) to law enforcement agencies in order to prevent or lessen a serious and imminent threat to a person's
or the public's health or safety.
- Health Oversight Activities. We may disclose your PHI to a health oversight agency that oversees the health
care system and is charged with responsibility for ensuring compliance with the rules of government health programs.
- Law Enforcement Officials. We may disclose your PHI to the police or other law enforcement officials as
required or permitted by law or in compliance with a court order or a grand jury or administrative subpoena.
- Judicial and Administrative Proceedings. We may disclose your PHI in the course of a judicial or administrative
proceeding in response to a legal order or other lawful process including a court order or a grand jury or administrative
- As required by law. We may use and disclose your PHI when required to do so by any other law not already referred
to in the preceding categories.
II. Uses and Disclosures Requiring Written Authorization
For any purpose other than the ones described above in Section I, we may only use or disclose your PHI when you give us written
authorization. Typical situations in which we will request authorization to disclose PHI include coordination of care with
community-based service providers and referrals for appropriate aftercare planning.
III. Your Rights Regarding Protected Health Information
- For Further Information; Complaints. If you want further information about your privacy rights, or wish to register
a complaint, you may contact our Privacy Office (contact information below). You may also file a complaint with the Office
for Civil Rights, U.S. Dept. of Health and Human Services. Trillium Family Services will not take action against you for
- Right to Request Additional Restrictions. You may request restrictions on our use and disclosure of your PHI (1)
for treatment, payment and health care operations, (2) to individuals involved with your care or with payment related to
your care. While we will consider all requests for additional restrictions carefully, we are not required to agree to a
- Right to Receive Confidential Communications. You may request, and we will accommodate, any reasonable written request
for you to receive your PHI by alternative means of communication or at alternative locations.
- Right to Revoke Your Authorization. You may revoke your authorization, except to the extent that we have taken action
upon it, by delivering a written revocation to the TFS Privacy Office.
- Right to Inspect and Copy Your Health Information. You may request access to your medical record file and billing records
maintained by us in order to inspect and request copies of the records. Under limited circumstances, we may deny you access to a
portion of your records. If you request copies, we will charge you $0.25 for each page plus postage cost.
- Right to Amend Your Records. You have the right to request that we amend PHI maintained in your medical record file or billing
records. If you desire to amend your records, please obtain an amendment request from the Privacy Office and submit the completed form
to the Privacy Office. We will comply with your request unless we do not believe that the information that your request be amended is
accurate and complete or other special circumstances apply.
- Right to Receive An Accounting of Disclosures. Upon request, you may obtain an accounting of certain disclosures of your PHI
made by us during any period of time prior to the date of your request provided such period does not exceed six years and does not
apply to disclosures that occurred prior to April 14, 2003.
IV. Effective Date and Duration of This Notice
This Notice is effective on April 14, 2003. We may change the terms of this Notice at any time. If we change this Notice, we may make the
new terms effective for all PHI that we maintain, including any information created or received prior to issuing the new notice. If we
change this Notice, we will post the new notice in waiting areas around Trillium Family Services sites and on our website,
V. Privacy Officer
You may contact our Privacy Officer at: Privacy Officer Trillium Family Services 4455 NE Highway 20 Corvallis, Oregon 97330 Telephone Number: