Your Information. Your Rights. Our Responsibilities.
Effective Date: 8/26/2025

At Wild Peloria, we respect your privacy and are committed to safeguarding your personal and health information.
 

This Notice explains:
1. How we may use and share your information.
2. The choices you have about your information.
3. Your privacy rights and how to exercise them.
4. Our legal duties to you.

1. How We May Use or Share Your Information
We typically use or share your health information for:

• Treatment: To coordinate your care across professionals.

• Billing: To submit claims or receive payment.

• Operations: To manage our services, improve quality, and keep in touch.

We may also share your information in special situations:

• Protecting public health or safety (e.g., disease reporting, abuse, safety threats).

• Research (under strict protections).

• Following the law (e.g., responding to court orders, audits).

• Organ or tissue donation, when applicable.

• In the event of death, working with coroners or funeral professionals.

• Workers’ compensation, law enforcement requests, or other government oversight.

• Legal proceedings, like lawsuits or subpoenas.

2. Your Choices
You have some say over certain uses or sharing of your information:

• You can ask us to contact you in a specific way, phone, email, or address preference.

• You can ask us not to share certain information with your health insurer if you paid out of pocket.

• You may tell us not to:

  • Include you in a directory or share information with family or friends.

  • Contact you for fundraising (and ask us not to again)

• We will not share your info for marketing, sale, or fundraising purposes without your written permission, and most psychotherapy notes require special consent.

3. Your Rights
You have the right to:

• Access your records: Request paper or electronic copies. We'll provide them within 30 days; a reasonable, cost-based fee may apply.

• Ask for corrections: If you believe something is wrong or incomplete, request an amendment. We'll respond in writing within 60 days if we can't honor the request.

• Limit what we share: You may request restrictions on how we use/share your info; we aren’t always required to agree, but will consider reasonable requests.

• See a log of disclosures: Get a list of times we shared your information (excluding for treatment, payment, or operations) over the past 6 years. One report per year is free; others may incur fees.

• Request a copy of this privacy notice at any time, even if you've agreed to receive it electronically.

• Designate someone else (like a guardian or power of attorney) to act on your behalf. We’ll verify their authority before honoring requests.

• File a complaint: If your rights were violated, contact us or the U.S. Department of Health and Human Services. We promise no retaliation.

4. Our Responsibilities

• We are legally obligated to protect the privacy and security of your protected health information.

• We will notify you promptly if a privacy breach occurs.

• We will follow the terms of this Notice and provide you a copy upon request.

• We will only use or share your information beyond these terms if you provide written authorization, which you can withdraw at any time.

• We may update this Notice in the future. Any changes will apply to all information we hold and be posted on our website and available upon request.

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How to Contact Us
If you have questions or want to exercise your rights, please reach out to us:
Wild Peloria
15480 SE 82 nd Dr., Ste. C, Clackamas, OR 97015
503-308-9665
info@wildpeloria.com

You may also file a complaint with the U.S. Department of Health and Human Services at www.hhs.gov/ocr/privacy/hipaa/complaints/.

At Wild Peloria, your story matters, and so does your privacy. We’re here to support your journey with care, transparency, and respect.