Your Privacy Matters

Siskiyou Vital Medicine is committed to maintaining the privacy of your protected health information. We understand information about your health is personal and private.

Effective 6/2015

Notice of Privacy Practices 



For More Information, or to report a problem please contact our Privacy Officer: (541) 210-5687

This Notice of Privacy Practices describe how Siskiyou Vital Medicine, LLC services, memberships, and independent members of the medical community, including our employees, may use and disclose your health care information to carry out treatment, payment, or health care operations and for other purposes that are permitted or required by law.

Your health information, in our possession may include information created or received by this organization, and may be in written, printed, electronic, or spoken word format. This information may include your medical history, current health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, other health-related services, or billing activity records.

We are required by law to maintain the privacy of your protected health information, to provide you with this notice, and to abide by the terms of this notice. This document details the ways in which Siskiyou Vital Medicine, LLC may use and disclose health information about you and describes your rights and our obligations regarding the use and disclosure of this information.

We may use and disclose your information for the following purposes without requesting or obtaining your consent or authorization:

TREATMENT: We may use and disclose your health information as necessary within Siskiyou Vital Medicine and with other outside health care providers to provide you with medical treatment or services. For example, health care professionals treating you will document information about services you receive. This record will be released to other health professionals assisting in your treatment to ensure that they are fully informed about your medical condition and treatment needs. 

PAYMENT: We may use and disclose your health information so the treatment and services you receive from our organization may be billed to and payment collected from you.

HEALTH CARE OPERATIONS: We may use and disclose your health information for purposes of maintaining and improving the quality and performance of Siskiyou Vital Medicine, LLC or that of another health care provider or health plan you have a relationship with.

APPOINTMENT REMINDERS: We may contact you as a reminder that you have an appointment for treatment or medical care at our clinic. 

DISASTER OR MAJOR EMERGENCY: We may disclose health information to other health care providers and to an entity assisting in a disaster relief effort to coordinate care so that your family can be notified about your condition and location.

TREATMENT ALTERNATIVES: We may tell you about or recommend possible treatment options or alternatives that may be of interest to you.

HEALTH-RELATED PRODUCTS AND SERVICES: We may tell you about health-related products or services that may be of interest to you.


We may use or disclose your health information for the following purposes, or in the following situations, subject to all applicable legal requirements and limitations: 

·      Avert a serious threat to your health or safety or the health and safety of the public or another person. 

·      Required by federal, state, or local law. 

·      Workers' compensation or similar programs that provide benefits for work-related injuries or illness. 

·      Public health risks in order to prevent or control disease, injury or disability; or report births, deaths, suspected abuse or neglect, non-accidental physical injuries, reactions to medications or problems with products. 

·      Health oversight activities for audits, investigations, inspections, or licensing purposes. This is necessary for the government to monitor the healthcare system, government programs, and compliance with civil rights laws. 

·      Lawsuits and disputes. If you are involved in litigation or a dispute, we may provide information in response to a court order, administrative order, subpoena, discovery request, or other lawful process.

·      Law enforcement in response to court order, criminal subpoena, warrant, or similar process. In other limited circumstances for purposes of reporting a crime, identifying or locating suspects, fugitives, material witnesses, missing persons, or crime victims. 

·      Coroners, medical examiners, and funeral directors to identify a deceased person or determine the cause of death or to perform other legally required duties.

·      Information not personally identifiable may be disclosed if it does not reveal who you are.

·      Incidental disclosure of your health information may occur as a by-product of lawful and permitted use and disclosure of your health information.  Reasonable safeguards are in place to protect your health information.

·      Business associates. There are some services provided in our organization through contracts with business associates. Examples may include laboratory, medical transcription, or record storage services. We may disclose your health information to our business associates so they can perform the jobs we've asked them to do and they are required to safeguard your information appropriately.


All other uses and disclosures of health information not covered by this notice or the laws that apply will be made only with your written authorization. If you provide us authorization to use or disclose health information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose health information about you for the reason covered by your written authorization.


You have the right to inspect and copy health or billing information that may be used to make decisions about your care. If you request a copy of the information, we may charge a copying and mailing fee that covers the costs associated with this request. 


You have the right to request an amendment if you believe health information we have about you is incorrect or incomplete. The request must be made in writing to and must include a reason for the amendment.

We may deny your request if:

·      The request is not in writing or does not include a reason to support the request.

·      The information was not created by us, unless the person or entity that created the information is no longer available to make the amendment.

·      The information is accurate and complete. 


You have the right to request an accounting of disclosures. This is a list of the disclosures we made of health information about you for purposes other than treatment, payment, health care operations, and a limited number of special circumstances. The list will also exclude any disclosures we made to you or those based on your written authorization.To obtain this printed list, you must submit a written request to us. It must state a time period, which may not be longer than six years and/or may not include dates before November 2014. The first list you request within a 12-month period will be free. For additional lists requested, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.


You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for services you receive, such as a family member or friend. To request restrictions, you must submit a written request to the us.


You have the right to request that we communicate with you about health matters in a certain way or at a certain time and place. Your request should be submitted in writing and must specify how or where you wish to be contacted. We will accommodate all reasonable requests. We will not ask you the reason for your request.


You have the right to a paper copy of this notice at any time. 


We reserve the right to change this notice at any time and to make the revised notice effective for health and billing information we already have about you, as well as any information we receive in the future. The current notice will be posted at SVM’s Clinic and will be made available to you at your request. The effective date of the notice will be on the first page in the top right-hand corner.


If you have any questions or concerns about this notice or our privacy practices, please contact us at (541) 210-5687.  If you believe your privacy rights have been violated, you may file a complaint with Siskiyou Vital Medicine at the following address:

Siskiyou Vital Medicine, 1840 E Barnett Rd, Suite B, Medford, OR, 97504

You may also contact the U.S. Department of Health and Human Services Office of Civil Rights at their toll-free telephone number (1-866-627-7748) or at the following address:

Office for Civil Rights U.S. Department of Health & Human Services 2201 Sixth Avenue - Mail Stop RX-11 Seattle, WA 98121

There will be no retaliation for filing a complaint.