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Notice of Privacy Practices

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This notice describes your rights and our responsibility to protect the privacy of your protected health information. It explains how your information is used, when it may be shared, your choices regarding these disclosures, how you can get access to this information, and how to file a complaint about a violation of the privacy or security of your health information or of your rights. You have a right to a copy of this notice in paper or electronic form and to discuss it with us if you have any questions. Please review this Notice carefully.

While you are receiving care from Nadejda Bespalova MD PLLC, referred to as (“We” or “Practice”) in this document, a record of information about you, your health history, and treatment is created and/or received. This is known as your " protected health information" or “PHI”. We are committed to protecting this personal information. The health and billing records we create and store are the property of the Practice, though the PHI within them generally belongs to you. In this notice, such information includes any substance use disorder (“SUD”) treatment records we maintain that are protected by 42 U.S.C. § 290dd-2 and 42 CFR Part 2 (“Part 2 records”). This notice is intended to serve as both our HIPAA Notice of Privacy Practices and our Part 2 Patient Notice.

REGULATORY REQUIREMENTS

We are required by law to maintain the privacy and security of your PHI, provide you with this notice about our legal duties and privacy practices, and follow the rules described in the notice currently in effect. We will also notify you if the privacy or security of your PHI has been compromised in a breach. We reserve the right to change our privacy practices and the terms of this notice at any time, making the new provisions effective for all health information we maintain. If material changes are made, we will post the revised notice in our office and on our website, and the revised notice will be available upon request electronically or by paper copy. The revised notice will show its effective data.

We will not use or share your information other than as described in this notice unless you give us written permission. Where Washington law or 42 CFR Part 2 provides greater privacy protection than HIPAA, we will follow the more protective law, as described in the sections below.

YOUR RIGHTS

You have certain rights regarding the use and disclosure of your PHI. You may exercise the following choices:

Restrictions:

You have the right to ask us in writing to limit how we use or share your PHI for treatment, payment, or health care operations, or what we share with people involved in your care. For example, you can request that we restrict disclosures to a spouse or family member. While we are not required to grant every request, we will honor any restrictions we agree to unless the information is needed to provide you emergency treatment. Additionally, if you (or someone other than your health plan on your behalf) pay out-of-pocket in full for an item or service, you can ask us not to share information about it with your health plan for payment or health care operations purposes. We will say “yes” unless a law requires us to share that information.

Alternative Communications:

You have the right to ask us to contact you about health matters in a specific way or at a specific location to preserve your confidentiality. For instance, you may request that we only contact you on your work phone. Your request must be submitted in writing, signed, and dated. We will let you know if we will grant your request.

Inspect and Copy:

You have the right to look at and receive a copy of your health record and other health information we maintain about you, with limited exceptions under the law. You must submit your request in writing and tell us whether you prefer a paper or electronic format. We will provide a timely response based on federal and state regulations. We will respond as promptly as circumstances require, and no later than 15 working days after we receive your written request, as required by Washington law. If unusual circumstances delay our response, we will tell you in writing why, and when the information will be available (no later than 21 working days after your request). If we keep your records electronically, you may request an electronic copy, and you may ask us to send a copy directly to another person you designate. In some cases, a reasonable fee may be charged to cover copying costs. If your request is denied, we will tell you why in writing and explain how you may request a review of the denial, where the law provides for one.

Amendment:

If you think information in your record is incorrect or missing, you have the right to ask us to make a correction or addition. Your request must be made in writing and should explain the reason for the change. We will respond no later than 10 days after we receive your request, as required by Washington law. We may deny your request in certain circumstances; if we do, we will tell you why in writing, and you have the right to file a statement of disagreement.

Accounting of Disclosures:

You have the right to request a list of the ways your PHI has been shared outside of the Practice. This list tracks disclosures made during the six years before your request and will show who received the information and why, but does not include disclosures made for treatment, payment, healthcare operations, or those you have explicitly authorized. The first request within a 12-month period is free, and we will notify you of any processing fees before fulfilling subsequent requests within the same year.

Right to Copy of Notice:

You have the right to receive a paper copy of this notice at any time upon request, even if you have previously agreed to receive it electronically. You may also ask questions about this notice by contacting our Privacy Officer at (206) 552-9659 or nbespalova@nadejdabespalovamd.com. This notice is also available in our office and on our website.

Persons Acting on Your Behalf:

If someone has legal authority to act as your personal representative, such as a person with your health care power of attorney or your legal guardian, that person can exercise your rights and make choices about your health information. We will confirm that the person has legal authority before we act.

HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION

Following certain rules, the Practice may use and share your PHI for the following purposes without your written authorization. Each category is subject to the additional protections for Part 2 records and for information protected by Washington law described later in this notice.:

For Treatment:

We use and share your information to give, coordinate, or arrange your medical treatment. We may also share this information with your other care providers in the community or for a formal referral to help them stay informed. Additionally, we may contact you directly to remind you about upcoming appointments, provide you with test results or information about treatment alternatives and health-related benefits.

Substance Use Disorder Records:

If we have SUD treatment records about you that are subject to 42 CFR Part 2, we will not use or share them for treatment, payment, or health care operations without your written consent, and we will not use or share them in any civil, criminal, administrative, or legislative investigation or proceeding against you without (1) your written consent or (2) a court order accompanied by a subpoena or other legal mandate requiring disclosure.

For Payment:

We use and share your information to bill and collect payment for the healthcare services provided to you. For instance, we include your diagnosis, procedures, and supplies when billing your health insurance plan directly if contracted with our Practice. If your care is not covered by a health plan, we bill you or the person you designate as responsible for your payment.

For Healthcare Operations:

We may use and share your information to schedule, check, and improve our services. This includes evaluating the performance of staff, conducting quality assessments, and reviewing compliance guidelines. This also encompasses contracting with third-party Business Associates (such as billing services or accountants) who assist with our operations, provided they agree in writing to strictly safeguard your health information.

As Required by Law and Law Enforcement:

We may disclose your PHI when required to do so by applicable federal, state, or local laws, and in response to a court or administrative order. We may respond to a subpoena or discovery request only if the conditions required by law are met; Washington law generally requires that you receive advance notice and an opportunity to object before we disclose your records in response to a subpoena or discovery request. We may also share limited information with law enforcement officials as permitted by federal and Washington law, such as in response to a warrant or court order, or to report a crime on our premises.

For Public Health Activities and Public Health Risks

We may disclose your information to support vital public health activities. This includes reporting births and deaths, preventing or controlling disease, reporting adverse reactions to medications or problems with products, reporting suspected abuse or neglect to public authorities, and notifying government officials or individuals who may be at risk of contracting or spreading a communicable disease.

For Health Oversight Activities

We may share your information with government oversight agencies (such as the Department of Health) for activities authorized by law, including audits, investigations, inspections, and licensure or disciplinary proceedings necessary to monitor the healthcare system.

Coroners, Medical Examiners and Funeral Directors

We may give necessary health information to coroners, medical examiners, and funeral directors consistent with applicable law so they can identify a decedent, determine a cause of death, or otherwise perform their legal duties.

Research

Your information may be used or shared for medical research approved by an Institutional Review Board (IRB) or privacy board that enforces strict policies to protect your privacy. We may also allow researchers to review information to prepare a research project, as long as they do not remove any identifying information from the Practice. Research using Part 2 records must also meet the requirements of 42 CFR Part 2..

To Avoid a Serious Threat to Health or Safety

We may share your PHI with appropriate individuals or law enforcement to prevent or reduce a serious, immediate threat to your health and safety, or to protect the safety of the public or another person.

Specialized Government Functions

We may disclose health information to authorized government officials for specific functions required by law, such as national security, military and veteran activities for U.S. and foreign personnel.

Workplace Injury or Illness

Washington State law requires the disclosure of PHI to the Department of Labor and Industries, your employer, and the associated payer for workers’ compensation and crime victims’ claims. we may share information as needed for workers' compensation and crime victims' compensation claims, as Washington law allows..

Correctional Institutions

If you are currently in jail or prison, we may disclose your health information as necessary to maintain your health and ensure the safety of other individuals or correctional staff.

Disaster Relief

We may share your health information with authorized disaster relief agencies to help notify your family or close friends of your location and general medical condition during an emergency.

Organ-Procurement Organizations

Consistent with applicable laws, we may share health information with organ-procurement organizations or transplant centers to facilitate tissue or organ donation and transplantation.

Food and Drug Administration (FDA)

For tracking or reporting issues related to food, nutritional supplements, or medical products, we may disclose relevant health information to the FDA or entities under its jurisdiction.

De-Identifying Information

We may use your PHI to create data that cannot be linked back to you by completely removing any identifying personal data points.

Disclosures to You or for HIPAA Compliance Investigations

We will disclose your information directly to you or your personal representative upon request. We must also share your information with the Department of Health and Human Services Office for Civil Rights to prove our compliance with the Health Insurance Portability and Accountability Act (HIPAA).

Disclosures to Individuals Involved in Your Health Care or Payment for Your Health Care

Unless you object, Practice may disclose your PHI to a family member, other relative, friend, or other person you identify as involved in your health care or payment for your health care, limited to information relevant to that person's involvement. If you are not present or are unable to agree or object (for example, in an emergency), we may share information if we believe it is in your best interest. We will not share Part 2 records with family members or others under this paragraph without your written consent, except as Part 2 permits.

USES AND DISCLOSURES THAT REQUIRE YOUR EXPLICIT AUTHORIZATION

Certain types of data use require your written permission:

  • Psychotherapy Notes: If we record or maintain psychotherapy notes, we must obtain your authorization for almost all uses and disclosures of these notes.
  • Substance Use Disorder Counseling Notes: If we keep SUD counseling notes (a clinician's notes analyzing the contents of a SUD counseling session, kept separate from the rest of your record), we will not use or share them without a separate written consent that is not combined with consent for any other type of record, except as Part 2 permits.
  • Marketing Communications: We must obtain your authorization to use or disclose your health information for marketing purposes, excluding face-to-face communications, promotional gifts of nominal value, or direct communications regarding currently prescribed drugs (such as refill reminders).
  • Sale of Health Information: Any disclosures that constitute a financial sale of your health information strictly require your written authorization.

Any other uses or disclosures not explicitly detailed in this notice will be made only with your written authorization. If you give us permission, you can cancel it in writing via a written revocation at any time. Once canceled, we will no longer share your information for those reasons, though we cannot claw back disclosures that were already made while the permission was active or if the authorization was initially required to obtain insurance.

SPECIAL PROTECTIONS FOR SUBSTANCE USE DISORDER (PART 2) TREATMENT RECORDS

If we maintain records of your substance use disorder diagnosis, treatment, or referral for treatment that are protected by 42 U.S.C. § 290dd-2 and 42 CFR Part 2, those records receive additional protection. If another section of this notice describes a use or disclosure that Part 2 does not allow, we will follow Part 2,

Consent for Treatment, Payment, and Health Care Operations

We will ask for your written consent before we use or share Part 2 records for treatment, payment, or health care operations. You may give a single consent for all future uses and disclosures for these purposes, or you may give consent for more limited purposes; however, limiting your consent may affect the services we can provide or how you pay for services. You may revoke your consent in writing at any time, except to the extent we have already acted in reliance upon your consent.

Other Uses and Disclosures with Consent

With your written consent, we may share Part 2 records with anyone you identify in the consent; to report your participation in treatment required by the criminal justice system; and to report prescribed substance use disorder medications to Washington's prescription monitoring program when required by law.

Redisclosure

When you consent to uses and disclosures for treatment, payment, and health care operations, we may share your information with other substance use disorder programs, health care providers, and health plans for those purposes. If the recipient is subject to HIPAA, it may use and share your information again without your consent as HIPAA allows. However, your information still cannot be used in legal proceedings against you unless you consent or there is a Part 2 court order and a subpoena or similar legal obligation.

Uses and Disclosures Permitted Without Consent

Part 2 permits us to use or share Part 2 records without your consent only in limited situations, including the following:

  • Communications within our Practice and with contractors (qualified service organizations) that help us operate and agree to protect your information;
  • To medical personnel during a bona fide medical emergency, and to the Food and Drug Administration to help notify you or your doctor about unsafe products;
  • To public health authorities, in a form that does not identify you;
  • For scientific research that meets Part 2 requirements; researchers may not identify you in their reports;
  • For management and financial audits and program evaluations, as long as the recipients agree to return or destroy the information and not use it against you;
  • To report to law enforcement a crime, or threat of a crime, committed on our premises or against our staff;
  • To report suspected child abuse and neglect, limited to the information required by Washington law;
  • For inquiries into the cause of death of a deceased patient, as allowed by law; and
  • In response to a court order that meets Part 2 requirements.

Legal Proceedings and Investigations

  • We will not use or share your Part 2 records, or provide testimony about them, in any civil, criminal, administrative, or legislative proceeding against you without your written consent or a court order.
  • We will respond to a court order only if it is accompanied by a subpoena or other similar legal mandate requiring us to comply.
  • We will use or share your information in a proceeding against you based on a court order only after you have received notice and an opportunity to be heard, or you tell us that you have received notice.
  • We may use or share your information to respond to a legal proceeding against our Practice based on a court order, and you may not be notified in advance. You have the right to seek to overturn or change the court order after you learn about it.

Fundraising

We do not conduct fundraising. If we ever wish to use your information (including Part 2 records) for fundraising, we will first give you clear and conspicuous notice and the opportunity to choose not to receive fundraising communications.

List of Disclosures Through Intermediaries

If you consent to share your Part 2 records through an intermediary (such as a health information exchange), you may request a list of the health care providers and others who received your information through that intermediary, as provided in 42 CFR § 2.24

ADDITIONAL PROTECTIONS UNDER WASHINGTON LAW

Washington law provides greater protection than HIPAA for some types of information. We will follow these laws, including:

  • Mental health information. We will share information about mental health services without your authorization only as permitted by Washington law (RCW 70.02.230 and 70.02.240), such as for treatment coordination, to avoid serious harm, or as otherwise required by law.
  • Sexually transmitted infections, including HIV. We will share this information only as permitted by RCW 70.02.220.
  • Reproductive and gender-affirming health care. Washington law limits the disclosure of information about protected reproductive and gender-affirming health care, including in response to out-of-state subpoenas and legal demands. We will follow those protections.
  • Subpoenas and discovery requests. Before we respond to a subpoena or discovery request for your records, Washington law generally requires that you receive advance notice and an opportunity to object, unless a court orders otherwise or you authorize the disclosure (RCW 70.02.060).

ADDITIONAL PRIVACY MATTERS

Shared Office Space

This Practice maintains a rental agreement for clinical and administrative space with Gina Guddat Properties/Live Well Alliance. Although multiple independent clinicians utilize this common facility, our Practice functions as an entirely separate entity. We maintain no shared patient records and do not participate in any joint financial or legal obligations regarding your healthcare. Each practitioner remains a distinct legal entity responsible for their own clinical judgments, professional conduct, and adherence to regulatory standards. As such, the Practice does not assume any legal liability or responsibility for the professional actions or disputes involving other providers within this shared environment. We take reasonable steps to limit incidental disclosures in shared areas.

Coverage by Alternative Providers

Occasionally, a licensed healthcare professional may manage the Practice during my absence due to vacation, illness, or professional commitments to maintain your continuity of care. Any provider authorized to treat you or review your medical record is legally obligated to adhere to the same HIPAA privacy standards, 42 CFR part 2 privacy standards, and federal and state laws, and strict confidentiality guidelines detailed in this Notice of Privacy Practices to protect your PHI.

Website

The Practice maintains a website at www.nadejdabespalovamd.com where this notice is posted. We do not disclose any patient information through this online platform and do not use online tracking technologies that share patient information with outside parties.

RIGHT TO FILE A COMPLAINT

We deeply value your privacy and the trust you place in us. If you are concerned that we have violated your privacy rights, or if you disagree with a decision regarding your records, you have the right to file a formal complaint without fear of retaliation or penalty. You may discuss your concerns or submit your complaint directly in writing to our designated officer:

Nadejda Bespalova MD (Acting Privacy/Security Officer) 200 1st Ave West, Suite 403 Seattle, WA 98119 Phone: 206-552-9659 Email: nbespalova@nadejdabespalovamd.com

You also have the right to file a written civil rights complaint with the government:

EFFECTIVE DATE

This Notice is effective as of September 1, 2026.