Your Information. Your Rights. Our Responsibilities.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Effective date: September 26, 2026
Privacy Contact: Marc Pellicciaro, MD / Magnolia Psychiatry LLC
Phone: (425) 467-1000
Email: info@MagnoliaPsychiatry.com
OUR RESPONSIBILITIES
We are required by law to maintain the privacy and security of your protected health information (PHI).
We must follow the duties and privacy practices described in the Notice that is currently in effect and provide you a copy of it.
We will notify you promptly if a breach occurs that may have compromised the privacy or security of your information, as required by law.
We will not use or disclose your information other than as described in this Notice unless you authorize us in writing or the law otherwise permits or requires it. You may revoke an authorization in writing, except to the extent we have already acted in reliance on it.
YOUR RIGHTS
You have the following rights regarding your health information. Ask us if you need help exercising any of these rights.
Get an electronic or paper copy of your medical record. You may ask to inspect or obtain a copy of your medical record and other health information we maintain about you. We generally will provide a copy or a summary within 30 days of your request. We may charge a reasonable, cost-based fee when permitted by law.
Ask us to correct your record. You may ask us to correct health information that you believe is incorrect or incomplete. We may deny the request in some circumstances, but if we do, we will explain the reason in writing, generally within 60 days.
Request confidential communications. You may ask us to contact you in a specific way (for example, by phone, email, patient portal, or at a particular number) or to send communications to a different address. We will accommodate reasonable requests.
Ask us to limit what we use or share. You may ask us not to use or disclose certain information for treatment, payment, or health care operations. We are not required to agree to every request. If we agree, we will follow the restriction except when disclosure is needed for emergency treatment or otherwise required by law.
If you pay out-of-pocket in full. If you pay in full for a health care service or item, you may ask us not to disclose information about that service or item to your health plan for payment or health care operations. We will honor the request unless a law requires disclosure.
Get an accounting of certain disclosures. You may ask for a list of certain disclosures of your health information made during the six years before your request. The accounting does not include disclosures for treatment, payment, health care operations, disclosures you authorized, and certain other disclosures excluded by law. One accounting in a 12-month period is provided without charge; additional accountings may be subject to a reasonable, cost-based fee.
Get a copy of this Notice. You may ask for a paper copy at any time, even if you agreed to receive it electronically.
Choose someone to act for you. If a person has legal authority to act as your personal representative, that person may exercise your privacy rights. We will verify that authority before acting.
File a complaint. You may complain to Magnolia Psychiatry if you believe your privacy rights were violated. 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 filing a complaint.
YOUR CHOICES
In the situations below, you may tell us your preferences. We will follow your instructions when required by law and will otherwise use professional judgment consistent with applicable law.
Family, friends, and others involved in your care or payment: We may share information that is directly relevant to their involvement if you agree, do not object when given the opportunity, or if you are unable to express a preference and we determine disclosure is in your best interest as permitted by law.
Disaster relief: We may share limited information with disaster relief organizations as permitted by law.
Appointment reminders and care communications: We may contact you about appointments, treatment, payment, prescriptions, or practice operations. You may request a preferred confidential method of communication.
Magnolia Psychiatry does not maintain a hospital directory and does not sell your health information. We do not currently use PHI for fundraising.
Written authorization is generally required. We will obtain your written authorization for uses or disclosures that require it, including most uses and disclosures of psychotherapy notes, most marketing that involves financial remuneration, and any sale of PHI. If you authorize a use or disclosure, you may revoke the authorization in writing as permitted by law.
HOW WE MAY USE OR DISCLOSE YOUR HEALTH INFORMATION
The law permits or requires us to use or disclose health information in certain circumstances. We use only the information reasonably necessary for the purpose when the minimum-necessary rule applies.
Treatment. We may use your health information and share it with other health professionals who are treating you when permitted by federal and Washington law. For example, we may coordinate care with another clinician, pharmacy, laboratory, or other treating provider.
Payment. We may use and disclose information to bill for services and obtain payment from you, your health plan, or another payer.
Health care operations. We may use and disclose information to operate the practice, improve care, conduct quality review, credentialing, licensing, auditing, legal or compliance activities, and other lawful health care operations.
Public health and safety. When legal requirements are met, we may disclose information for public health activities, reporting adverse events or certain communicable conditions, reporting suspected abuse or neglect, or to prevent or lessen a serious and imminent threat to a person or the public.
Research. We may use or disclose health information for research only when the applicable legal requirements are satisfied, such as with your authorization or an appropriate waiver or other permission allowed by law.
Required by law and health oversight. We will disclose information when federal or state law requires it. We may disclose information to health oversight agencies for activities authorized by law, including licensing, audits, inspections, and investigations.
Workers’ compensation and other government functions. We may disclose information as authorized by law for workers’ compensation, military or veterans’ activities, national security, correctional institutions, or other special government functions.
Law enforcement and legal proceedings. We may disclose information for lawful law-enforcement purposes or in response to a court or administrative order, subpoena, discovery request, or other lawful process only when the applicable federal and state requirements are met.
Coroners, medical examiners, and funeral directors. We may disclose information as permitted by law when an individual dies.
Other permitted or required disclosures. Other uses or disclosures may be made when specifically permitted or required by applicable law. When more protective federal or Washington law applies, we will follow the more protective requirement.
SPECIAL PROTECTIONS FOR MENTAL HEALTH AND SUBSTANCE USE DISORDER INFORMATION
Washington mental health information. Washington law may provide protections for mental health treatment information that are more restrictive than HIPAA. We generally will not disclose mental health treatment records without your written authorization unless the disclosure is permitted or required by applicable Washington or federal law. We will follow the more protective law when it applies.
Psychotherapy notes. Psychotherapy notes, when maintained separately from the rest of the medical record as defined by HIPAA, receive additional protection. Most uses and disclosures of psychotherapy notes require your written authorization.
Substance use disorder records subject to 42 CFR Part 2. To the extent Magnolia Psychiatry creates, receives, or maintains substance use disorder patient records that are subject to 42 CFR Part 2, those records receive additional federal confidentiality protections. Such Part 2 records generally may not be used or disclosed in civil, criminal, administrative, or legislative investigations or proceedings against you without your written consent or a court order and subpoena that meet Part 2 requirements.
Other specially protected information. Certain information, including some substance use disorder, sexually transmitted infection, HIV, genetic, reproductive, and minor-consented health information, may be subject to additional federal or Washington protections. We will use and disclose such information only as permitted or required by the law that applies.
CHANGES TO THIS NOTICE
We may change the terms of this Notice and make the revised Notice effective for all health information we maintain, including information created or received before the change. If we make a material change, the revised Notice will be available upon request, in our office, and on our website if we maintain a website that provides information about our services.
QUESTIONS OR COMPLAINTS
Questions about this Notice or Magnolia Psychiatry’s privacy practices may be directed to the Privacy Contact listed at the beginning of this Notice.
You may also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, 200 Independence Avenue, S.W., Washington, D.C. 20201; phone 1-877-696-6775; or online at https://www.hhs.gov/hipaa/filing-a-complaint/. We will not retaliate against you for filing a complaint.