Notice of Privacy Practices



Effective Date: January 1, 2014

About this Notice

Dahl Memorial Clinic understands that information we collect about you and your health is personal. Keeping your health care information private is one of our most important responsibilities. In addition, we are required by law to keep your health care information from others who do not need it, to give you this Notice explaining our privacy practices, and to abide by the terms of this Notice.

A.  How we may use and disclose your Protected Health Information

  • For Treatment. We may use or disclose your Protected Health Information to give you medical treatment or services and to manage and coordinate your medical care. For example, your Protected Health Information may be provided to a physician or other specialist to whom you have been referred.
  • For Payment. We may use and disclose your Protected Health Information so that we can bill for the treatment and services you receive from us. For example, we may need to give your health plan information about your treatment in order for your health plan to agree to pay for that treatment. We may also disclose information to other healthcare providers to assist them in obtaining payment.
  • Workers Compensation.  We may disclose your Protected Health Information as necessary to comply with workers’ compensation laws. For example, we may make periodic reports to your employer about your condition. We are also required by law to report cases of occupational injury or illness to the employer or workers’ compensation insurer.
  • For Health Care Operations. We may use your Protected Health Information to internally review the quality of the treatment and services you receive and to evaluate the performance of our team members in caring for you. Information on the services you received may be used to support budgeting and financial reporting.
  • Minors. We may disclose the Protected Health Information of minor children to their parents or guardians unless such disclosure is otherwise prohibited by Law.
  • As Required by Law. We will disclose Protected Health Information about you when required to do so by international, federal, state, or local law. In addition, we may disclose Protected Health Information for law enforcement purposes so long as applicable legal requirements are met.
  • Business Associates. We may disclose Protected Health Information to our business associates who perform functions on our behalf or provide us with services. All of our business associates are obligated, under contract with us, to protect the privacy and ensure the security of your Protected Health Information.
  • Public Health Reporting. Your Protected Health Information may be disclosed to public health agencies as required by law for purposes such as preventing or controlling disease, injury or disability; and reporting abuse, neglect or domestic violence. We also report birth, death and immunization information.
  • Health Oversight Activities. We may disclose Protected Health Information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, licensure, and similar activities.
  • Notification and Communication with Family. We may disclose your Protected Health Information to notify a family member, your personal representative or another person responsible for your care about your location, your general condition or, unless you had instructed us otherwise, in the event of your death.

B.  Other Uses of Your Protected Health Information for Which We Must Give You the Opportunity to Opt Out

  • Individuals involved in your care. Unless you object, we may disclose to a member of your family, a close friend, or any other person you identify, your Protected Health Information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment.
  • Disaster Relief. We may disclose your Protected Health Information to disaster relief organizations in order to coordinate your care, or notify family and friends of your location or condition in a disaster.


C.  Your Rights Regarding Your Protected Health Information

  • Right to Inspect and Copy. You have the right to inspect and copy your Protected Health Information. We have up to 30 days to make your Protected Health Information available to you. We may charge you a reasonable fee for the costs of copying, mailing or other supplies associated with your request. We can also provide you with a summary of your Protected Health Information rather than the entire record if you request such an alternative form. We will make every effort to provide access to your Protected Health Information in the form or format you request.
  • Right to Receive a Notice of a Breach. You have the right to be notified in the event of a breach of any of your Protected Health Information.
  • Right to Request Amendments. If you feel that the Protected Health Information we have is incorrect or incomplete, you may ask us to amend the information. The request must be made in writing and it must tell us the reason for your request. If we deny your request, you have the right to file a statement of disagreement with us.
  • Right to an Accounting of Disclosures. You have the right to receive an accounting of how and to whom your Protected Health Information has been disclosed. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this notice.
  • Right to Request Restrictions. You have the right to request a restriction or limitation on the Protected Health Information we use or disclose for treatment, payment, or healthcare operations or information we disclose about you to someone who is involved in your care or payment for your care. To request a restriction, you must submit a written request. Your request must state the specific restriction requested and to whom you want the restriction to apply. We are not required to agree to your request except for “Out of Pocket” payments as described below.
  • Out-of-Pocket Payments. If you paid out of pocket in full for a specific item or service, you have the right to ask that your Protected Health Information with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and we will honor that request.
  • Right to Request Confidential Communications. You have the right to request that we communicate with you only in certain ways to preserve your privacy. For example, you may request that we contact you by mail or call you at a specific number, or that we not leave messages related to your care on your phone.
  • Right to a Paper Copy of this Notice.

 D. Complaints. If you have a complaint or you believe your privacy rights have been violated, you may send a letter outlining your concerns to the contact person below. Your healthcare services will not be affected by any complaint made.

Executive Director
Dahl Memorial Clinic
350 14th Ave
PO Box 537
Skagway, AK 99840

If you are not satisfied with the manner in which we handle a complaint, you may submit a formal complaint to the Secretary of the US Department of Health and Human Services, 200 Independence Ave, S.W., Washington, D.C. 20201. Call 877-696-6775 or go to for more information.

We reserve the right to change this notice. Changes in our policies and practices may be required by federal or state laws. Upon request, we will provide you with the most recently revised notice. The revised policies and practices will be applicable to all Protected Health Information we maintain.