Refine, MD Northwest Notice of Privacy Practices

HIPAA Notice for Protected Health Information

Effective Date: September 23, 2026

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.

This Notice describes the privacy practices of Puget Sound Plastic Surgical Group, PLLC, doing business as Refine, MD Northwest, for protected health information governed by the Health Insurance Portability and Accountability Act (HIPAA). It also describes your rights and our responsibilities regarding protected health information. This Notice applies to the practice locations listed at the end of this document and to workforce members and health care professionals participating in the practice’s covered activities as permitted by law.

Your Rights

You have rights regarding your health information. Subject to applicable law, these rights include the following.

Get an Electronic or Paper Copy of Your Medical Record

You may ask to inspect or receive an electronic or paper copy of your medical record and other health information we maintain about you. We will provide access or a copy as required by applicable federal and Washington law. A reasonable, cost-based fee may apply where permitted.

Ask Us to Correct Your Medical Record

You may ask us to correct health information you believe is incorrect or incomplete. We may deny a request in circumstances permitted by law, and when required we will explain the reason in writing.

Request Confidential Communications

You may ask us to contact you in a specific way or at a different address. We will accommodate reasonable requests as required by law.

Ask Us to Limit What We Use or Share

You may ask us not to use or disclose certain health information for treatment, payment, or health care operations. We are not required to agree to every restriction. If you pay for a health care item or service completely out of pocket, you may ask us not to disclose information about that item or service to your health plan for payment or health care operations, and we will honor the request unless a law requires disclosure.

Get an Accounting of Certain Disclosures

You may ask for an accounting of certain disclosures of your health information made during the period required by law. The accounting does not include every type of disclosure, including many disclosures for treatment, payment, and health care operations. We will provide the first accounting within the applicable period without charge and may charge a reasonable, cost-based fee for additional accountings when permitted.

Get a Copy of This Notice

You may request a paper copy of this Notice at any time, even if you previously agreed to receive it electronically.

Choose Someone to Act for You

If a person has legal authority to act on your behalf, such as a legal guardian, personal representative, or authorized health care representative, that person may exercise your rights as permitted by law. We may verify the person’s authority before acting.

File a Complaint

If you believe your privacy rights have been violated, you may contact our Privacy Officer at info@refinemdnw.com, (425) 420-2663, (425) 739-0808, or by mail at either practice location listed below. 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.

HHS complaint information: www.hhs.gov/hipaa/filing-a-complaint

Your Choices

For certain uses and disclosures, you have a choice about whether and how we share your information. Tell us your preference, and we will follow it when applicable law gives you that choice.

• Sharing information with family members, close friends, or others involved in your care or payment for your care.
• Sharing information in a disaster relief situation.
• Certain fundraising communications, when applicable. You may tell us not to contact you again for fundraising.
• Certain other disclosures for which applicable law gives you a choice.

We will obtain your written authorization before using or disclosing protected health information for marketing when HIPAA requires authorization, before selling protected health information as defined by HIPAA, and before most uses or disclosures of psychotherapy notes when applicable. You may revoke an authorization in writing, subject to actions already taken in reliance on it.

If we maintain substance use disorder patient records subject to 42 CFR Part 2, we will follow the additional federal confidentiality protections that apply to those records, including restrictions on their use in civil, criminal, administrative, or legislative proceedings against a patient unless the required consent, court order, and other legal requirements are satisfied.

How We Typically Use or Share Health Information

Treatment

We may use and disclose your health information to physicians, nurses, facilities, laboratories, pharmacies, imaging providers, and other health care professionals involved in providing, coordinating, or managing your treatment.

Health Care Operations

We may use and disclose health information to operate our practice, improve quality, manage services, train personnel, conduct compliance and accreditation activities, evaluate performance, and contact you when necessary.

Payment

We may use and disclose health information to bill for services and obtain payment from you, health plans, financing arrangements, or other responsible parties when applicable.

Other Uses and Disclosures Permitted or Required by Law

We may use or disclose health information without your written authorization when applicable law permits or requires it, subject to the conditions and limits imposed by law. Examples include:

• Public health and safety activities, including certain disease reporting, product recalls, adverse event reporting, or preventing a serious threat to health or safety.
• Health oversight activities authorized by law.
• Research when legal requirements and required approvals are satisfied.
• Workers’ compensation and similar programs as authorized by law.
• Certain law enforcement or government requests.
• Organ and tissue donation activities when applicable.
• Coroners, medical examiners, or funeral directors as permitted by law.
• Court or administrative proceedings, orders, subpoenas, or other legal processes when legal requirements are satisfied.
• Other disclosures required or permitted by federal or Washington law.

Washington law may impose additional protections on certain health care information. When Washington law provides greater privacy protection than HIPAA, we follow the more protective requirement when it applies. Washington Chapter 70.02 RCW also provides patients rights involving access, correction, authorization, and disclosure of health care information.

Our Responsibilities

• We are required by law to maintain the privacy and security of protected health information.
• We will notify affected individuals as required if a breach occurs that compromises the privacy or security of protected health information.
• We must follow the duties and privacy practices described in the Notice currently in effect.
• We will not use or disclose protected health information other than as described in this Notice unless you authorize us in writing or another law permits or requires the use or disclosure.
• We will provide this Notice at first service delivery as required and make a good-faith effort to obtain written acknowledgment of receipt.

Changes to This Notice

We may change the terms of this Notice, and changes may apply to health information we already maintain as well as information we receive in the future. A revised Notice will be available upon request, at our practice locations, and on our website as required by law.

Privacy Contact

Privacy Officer