OHSU Notice of Privacy Practices

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 March 10, 2026

PURPOSE OF THIS NOTICE.
Oregon Health & Science University ("OHSU") is committed to preserving the privacy of your health information. In fact, we are required by law to do so for any health information created or received by us. OHSU is required to provide this Notice of Privacy Practices ("Notice") to you. The Notice tells you how we can and cannot use and disclose the health information that you have given to us or that we have learned about you when you were a patient in our system. It also tells you about your rights and our legal duties concerning your health information.

OHSU is required to abide by this Notice and any future changes to the Notice that we are required or authorized by law to make at all OHSU locations, including the schools of Dentistry, Medicine, Nursing, and Science & Engineering; OHSU Hospital, and Doernbecher Children's Hospital; numerous primary care and specialty clinics; multiple research institutes and centers; and several community service and outreach programs. This Notice applies to the practices of:
- All OHSU employees, volunteers, students, residents and service providers, including clinicians, who have access to health information.
- Any health care professional authorized to enter information into your OHSU health record.
- Any non-OHSU clinicians who might otherwise have access to your health information created or kept by OHSU, as a result of, for example, their call coverage for OHSU clinicians.
  
  For the rest of this Notice, "OHSU," "we" and "us" will refer to all services, service areas, and workers of OHSU. When we use the words "your health information," we mean any information that you have given us about you or and your health, as well as information that we have received while we have taken care of you (including health information provided to OHSU by those outside of OHSU).
  
  A copy of the current Notice with an effective date in clinical locations and on our website at www.ohsu.edu/xd/about/services/integrity/ips.npp.cfm.
USES AND DISCLOSURES OF HEALTH INFORMATION FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS AT OHSU.
1. Treatment, Payment and Health Care Operations.
  The following section describes different ways that we use and disclose health information for treatment, payment and health care operations. For each of those categories, we explain what we mean and give one or more examples. Not every use or disclosure will be noted and there may be incidental disclosure that are a byproduct of the listed uses and disclosures. The ways we use and disclose health information will fall within one of the categories.

a. For Treatment. We may use your health information to provide you with medical or dental treatment or services. We may disclose your health information to staff physicians, staff dentists, post-graduate fellows, midwives or nurse practitioners, and other personnel involved in your health care. We may also disclose your health information to students and resident physicians who, as a part of their OHSU educational programs (and while supervised by physicians or dentists), are involved in your care. Treatment includes (a) activities performed by nurses, office staff, hospital staff, technicians and other types of health care professionals providing care to you or coordinating or managing your care with third parties, (b) consultations with and between OHSU providers and other health care providers, and (c) activities of non-OHSU providers or other providers covering an OHSU practice by telephone or serving as the on-call provider.

For example, a physician or dentist treating you for an infection may need to know if you have other health problems that could complicate your treatment. That provider may use your medical history to decide what treatment is best for you. They may also tell another provider about your condition so that he or she can decide the best treatment for you.

b. For Payment. We may use and disclose your health information so that we may bill and collect payment from you, an insurance company, or someone else for health care services you receive from OHSU. We may also tell your health plan about a treatment you are going to receive to obtain prior approval, or to determine whether your plan will pay for the treatment.

For example, we may need to give your health plan information about surgery you received at OHSU so your health plan will pay us or reimburse you for the surgery.

c. For Health Care Operations. We may use and disclose your health information in order to run the necessary administrative, educational, quality assurance and business functions at OHSU.

For example, we may use your health information to evaluate the performance of our staff in caring for you. We may also use health information about patients to help us decide what additional services we should offer, how we can improve efficiency, or whether certain treatments are effective. Or we may give health information to doctors, nurses, technicians, or health profession students for review, analysis and other teaching and learning purposes.

2. Fundraising Activities.
As a part of OHSU's healthcare operations, we may use and disclose a limited amount of your health information internally, or to the OHSU Foundation and Doernbecher Children's Hospital Foundation (collectively, "Foundations") to allow them to contact you to raise money for OHSU. The health information released for these fundraising purposes can include your name, address, other contact information, gender, age, date of birth, dates on which you received service, health insurance status, the outcome of your treatment at OHSU and your treating physician's name and department at OHSU. Any fundraising communications you receive from OHSU or its Foundations will include information on how you can elect not to receive any further fundraising communications from OHSU.

3. Uses and Disclosures You Can Limit.

a. Hospital Directory. Unless you notify us that you object, we may include certain information about you in the hospital directory in order to respond to inquiries from friends, family, clergy and others who inquire about you when you are a patient in the hospital. Specifically, your name, location in the hospital and your general condition (e.g., good, fair, serious, critical) may be released to people who ask for you by name. In addition, your religious affiliation may be given to a member of the clergy, such as a priest or rabbi, even if they don't ask for you by name.

b. Family and Friends. Unless you notify us that you object, we may provide your health information to individuals, such as family and friends, who are involved in your care or who help pay for your care. We may do this if you tell us we can do so, or if you know we are sharing your health information with these people and you don't stop us from doing so. There may also be circumstances when we can assume, based on our professional judgment, that you would not object. For example, we may assume you agree to our disclosure of your information to your spouse if your spouse comes with you into the exam room during treatment.

Also, if you are not able to approve or object to disclosures, we may make disclosures to a particular individual (such as a family member or friend), that we feel are in your best interest and that relate to that person's involvement in your care. For example, we may tell someone who comes with you to the emergency room that you suffered a heart attack and provide updates on your condition. We may also make similar professional judgments about your best interests that allow another person to pick up such things as filled prescriptions, medical supplies and X-rays.

C. OTHER PERMITTED USES AND DISCLOSURES OF HEALTH CARE INFORMATION.
We may use or disclose your health information without your permission in the following circumstances, subject to all applicable legal requirements and limitations:

Required By Law. As required by federal, state, or local law.
Public Health Activities. For public health reasons in order to prevent or control disease, injury or disability; or to report births, deaths, suspected abuse or neglect, non-accidental physical injuries, reactions to medications, school immunizations under certain circumstances or problems with products.
Victims of Abuse, Neglect or Domestic Violence. To a government authority authorized by law to receive reports of abuse, neglect or domestic violence when we reasonably believe you are the victim of abuse, neglect or domestic violence and other criteria are met.
Health Oversight Activities. To a health oversight agency for audits, investigations, inspections, licensing purposes, or as necessary for certain government agencies to monitor the health care system, government programs, and compliance with civil rights laws.
Lawsuits and Disputes. In response to a subpoena, discovery request or a court or administrative order, if certain criteria are met.
Law Enforcement. To a law enforcement official for law enforcement purposes as required by law; in response to a court order, subpoena, warrant, summons or similar process; for identification and location purposes if requested; to respond to a request for information on an actual or suspected crime victim; to report a crime in an emergency; to report a crime on OHSU premises; or to report a death if the death is suspected to be the result of criminal conduct.
Coroners, Medical Examiners and Funeral Directors. To a coroner or medical examiner, (as necessary, for example, to identify a deceased person or determine the cause of death) or to a funeral director, as necessary to allow him/her to carryout his/her activities.
Organ and Tissue Donation. To organizations that handle organ procurement or organ, eye or tissue transplantation, or to an organ donation bank, as necessary to facilitate a donation and transplantation.
Research. For research purposes under certain limited circumstances. Research projects are subject to a special approval process. Therefore, we will not use or disclose your health information for research purposes until the particular research project, for which your health information may be used or disclosed, has been approved through this special approval process.
Serious Threat to Health or Safety; Disaster Relief. To appropriate individual(s)/organization(s) when necessary (i) to prevent a serious threat to your health and safety or that of the public or another person, or (ii) to notify your family members or persons responsible for you in a disaster relief effort.
Military. To appropriate domestic or foreign military authority to assure proper execution of a military mission, if required criteria are met.
National Security; Intelligence Activities; Protective Service. To federal officials for intelligence, counterintelligence, and other national security activities authorized by law, including activities related to the protection of the President, other authorized persons or foreign heads of state, or related to the conduct of special investigations.
Inmates. To a correctional institution (if you are an inmate) or a law enforcement official (if you are in that person's custody) as necessary (a) to provide you with health care; (b) to protect your or others' health and safety; or (c) for the safety and security of the correctional institution.
Workers' Compensation. As necessary to comply with laws relating to workers' compensation or similar work-related injury program.

D. WHEN WRITTEN AUTHORIZATION IS REQUIRED.
Other than for those purposes identified above in Sections B and C, we will not use or disclose your health information for any purpose unless you give us your specific written authorization to do so. Special circumstances that require an authorization include most uses and disclosures of your psychotherapy notes, certain disclosures of your test results for the human immunodeficiency virus or HIV, uses and disclosures of your health information for marketing purposes that encourage you to purchase a product or service, and for sale of your health information with some exceptions. If you give us authorization, you can withdraw this written authorization at any time. To withdraw your authorization, deliver or fax a written revocation to OHSU Health Information Management, Mail Code OP17A, 3181 S.W. Sam Jackson Park Road, Portland, OR 97239; fax: 503-494-6970. If you revoke your authorization, we will no longer use or disclose your health information as allowed by your written authorization, except to the extent that we have already relied on your authorization.

E. ORGANIZED HEALTH CARE ARRANGEMENTS

OHSU participates in one or more Organized Health Care Arrangements (“OHCA”). OHSU can share your health information with other participants for treatment, payment and health care operations activities related to the OHCA. You can find a list of OHCA participants on OHSU’s website.

F. SUBSTANCE USE DISORDER RECORDS (42 CFR PART 2)

If we hold your Substance Use Disorder (SUD) records, subject to 42 CFR Part 2, we will not share that information for use in civil, criminal, administrative or legislative investigations or proceedings against you without (1) your written consent or (2) a court order and a subpoena. For more information, see the section entitled “OHSU’s 42 CFR Part 2 Patient Notice.”

G. YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION.
You have certain rights regarding your health information which we list below. In each of these cases, if you want to exercise your rights, you must do so in writing by completing a form that you can obtain from the OHSU Information Privacy and Security Office, Mail Code ITG05, 3181 S.W. Sam Jackson Park Road, Portland, OR 97239, or on the Web at www.ohsu.edu/xd/about/services/information-technology/information-privacy-security-ips/policies-forms.cfm. In some cases, we may charge you for the costs of providing materials to you. You can get information about how to exercise your rights and about any costs that we may charge for materials by contacting the OHSU Information Privacy and Security Office at 503-494-0219.

Right to Inspect and Copy. With some exceptions, you have the right to inspect and get a copy of the health information that we use to make decisions about your care. For the portion of your health record maintained in our electronic health record, you may request we provide that information to or for you in an electronic format. If you make such a request, we are required to provide that information for you electronically (unless we deny your request for other reasons). We may deny your request to inspect and/or copy in certain limited circumstances, and if we do this, you may ask that the denial be reviewed.
Right to Amend. You have the right to amend your health information maintained by or for OHSU, or used by OHSU to make decisions about you. We will require that you provide a reason for the request, and we may deny your request for an amendment if the request is not properly submitted, or if it asks us to amend information that (a) we did not create (unless the source of the information is no longer available to make the amendment); (b) is not part of the health information that we keep; (c) is of a type that you would not be permitted to inspect and copy; or (d) is already accurate and complete.
Right to an Accounting of Disclosures. You have the right to request a list and description of certain disclosures by OHSU of your health information.
Right to Request Restrictions. You have the right to request a restriction or limitation on the health information we use or disclose about you (a) for treatment, payment, or healthcare operations, (b) to someone who is involved in your care or the payment for it, such as a family member or friend, or (c) to a health plan for payment or health care operations purposes when the item or service for which OHSU has been paid out of pocket in full by you or someone on your behalf (other than the health plan). For example, you could ask that we not use or disclose information about a surgery you had, a laboratory test ordered or a medical device prescribed for your care. Except for the request noted in 4(c) above, we are not required to agree to your request. Any time OHSU agrees to such a restriction, it must be in writing and signed by the OHSU Privacy Officer or his or her designee.
Right to Request Confidential Communications. You have the right to request that we communicate with you about health matters in a certain way or at a certain place. OHSU will accommodate reasonable requests. For example, you can ask that we only contact you at work or by mail.
Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice, whether or not you may have previously agreed to receive the Notice electronically.
Right to be Notified of a Breach. You have the right to be notified if there is a breach – a compromise to the security or privacy of your health information –due to your health information being unsecured. OHSU is required to notify you within 60 days of discovery of a breach.

H. REVISIONS TO THIS NOTICE.
We have the right to change this Notice and to make the revised or changed Notice effective for health information we already have about you, as well as any information we receive in the future. Except when required by law, a material change to any term of the Notice may not be implemented prior to the effective date of the Notice in which the material change is reflected. OHSU will post the revised Notice at OHSU clinical locations and on its website and provide you a copy of the revised notice upon your request.

I. QUESTIONS OR COMPLAINTS.
If you have any questions about this Notice, please contact OHSU 503-494-8311. If you believe your privacy rights have been violated, you may file a complaint with OHSU or with the Secretary of the Department of Health and Human Services. To file a complaint with OHSU, contact OHSU at 503-494-8311. You will not be penalized for filing a complaint.

This Notice tells you how we may use and share health information about you. If you would like a copy of this Notice,
please ask your health care provider.

42 CFR Part 2 Patient Notice

As described in OHSU’s Notice of Privacy Practices, patients’ health information is protected by federal and state laws and regulations, including the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). Certain Substance Use Disorder (SUD) records are also protected by federal regulations under 42 CFR Part 2 (“Part 2”).

THIS NOTICE FOR OHSU’S PART 2 PROGRAMS DESCRIBES THE ADDITIONAL CONFIDENTIALITY PROTECTIONS THAT APPLY TO PART 2-PROTECTED SUBSTANCE USE DISORDER RECORDS, SPECIFICALLY:

HOW YOUR SUD HEALTH INFORMATION MAY BE USED AND DISCLOSED
YOUR RIGHTS WITH RESPECT TO YOUR SUD HEALTH INFORMATION
HOW TO FILE A COMPLAINT CONCERNING A VIOLATION OF THE PRIVACY OR SECURITY OF YOUR SUD HEALTH INFORMATION, OR OF YOUR RIGHTS CONCERNING YOUR INFORMATION
YOU HAVE A RIGHT TO A COPY OF THE NOTICE (IN PAPER OR ELECTRONIC FORM) AND TO DISCUSS IT WITH THE OHSU PRIVACY OFFICE AT 503-494-0219 OR PRIVACY@OHSU.EDU IF YOU HAVE ANY QUESTIONS

In this part of the Notice, your “SUD health information” means your Substance Use Disorder (SUD) patient records and “we/us” means OHSU’s 42 CFR Part 2 Programs.

A. YOUR RIGHTS REGARDING YOUR SUD HEALTH INFORMATION.

This section explains your rights regarding your SUD health information.

1. Right to Consent to Uses and Disclosures of your SUD health information. You have the right to consent to most of the uses and disclosures of your SUD health information, including providing a single consent for all future uses or disclosures for treatment, payment and health care operations purposes.

2. Right to Request Restrictions. You can ask us not to share certain SUD health information for treatment, payment or health care operations purposes. We are not required to agree to your request. If we agree to your request, we may still share this information if you need emergency treatment. If you pay for a service or health care item out-of-pocket or in full, you can ask us not to share that information with your health insurer. We will agree to that request unless a law requires us to share that information with your insurer.

3. Right to Obtain a Copy of this Notice. You have the right to request a paper copy of this notice at any time, even if you have already received an electronic version.

4. Right to Discuss this Notice. You can ask questions or obtain more information about this notice and our privacy practices by calling or emailing the contact person at the top of this Part 2 Notice.

5. Right to Choose Fundraising Communications. You have the right to a clear and obvious notice in advance of, and choice whether to receive, fundraising communications from an OHSU Part 2 Program. Please note that you may receive separate fundraising communications from OHSU as permitted by HIPAA based on services you receive outside of OHSU’s Part 2 Programs.

6. Right to File a Complaint. You have the right to file a complaint with OHSU by calling (503) 494-8311. You can also file a complaint with the U.S. Department of Health and Human Services’ Office for Civil Rights by sending a letter to 200 Independence Ave. S.W., Washington, D.C. 20201, calling 1 (877) 696-6775 or visiting their website. We will not retaliate against you for filing a complaint.

B. USES AND DISCLOSURES WITH YOUR CONSENT

With your written consent, we can use or share your SUD health information for all future uses and disclosures for treatment, payment and health care operations purposes.

With a separate written consent, we may also use and share your SUD health information:

To an individual or program of your choice
To prevent multiple enrollments in withdrawal management or maintenance treatment programs
To report participation in treatment required by the criminal justice system
To report prescribed substance use disorder treatment medications to a state prescription drug monitoring program when required by law.

C. REVOKING CONSENT

You have the right to revoke your consent by sending a written revocation to OHSU Health Information Management, Mail Code OP17a, 3181 SW Sam Jackson Park Rd., Portland, OR 97239. If you revoke your consent, we will no longer use or disclose your SUD health information as allowed by your written consent, except to the extent that we have already relied on it to make a use or disclosure. If you have been referred to treatment as a condition of any legal proceedings or processes, your right to revoke your consent may be limited and should be explained in the consent you signed.

D. USES AND DISCLOSURES WITHOUT YOUR CONSENT

We may be allowed or required to share your SUD health information without your written consent for the following purposes:

1. To communicate within our program and with contractors. We can share your SUD health information within our program, with an organization that has administrative control over our program and with contractors who help us run our program.

2. For medical emergencies. We can share your SUD health information during a bona fide medical emergency with the health care providers and personnel responding to your emergency. We can also share your SUD health information to help the federal Food and Drug Administration to notify you or your provider about unsafe products you may be using.

3. For certain public health purposes. We can share SUD health information that does not identify you for certain situations including to prevent disease and report adverse reactions to medications.

4. To aid scientific research. We can use or share your SUD health information to conduct or help with health research. Researchers cannot include any patient identifying information in their reports about the research without your consent.

5. To respond to management and financial audit and program evaluations. We can use or share your SUD health information to improve the quality of our services, obtain needed credentials and cooperate with oversight agencies for activities authorized by law, provided those who view or receive the information agree to destroy or return it once their work is complete and agree not to use it against you.

6. To assist with cause of death inquiries. We can share patient identifying information about a deceased patient as permitted or required by law.

7. To report suspected child abuse and neglect. We can share patient identifying information that is permitted or required by law to report child abuse or neglect.

8. To prevent or address crimes or threats of crimes on premises. We may report to law enforcement when a patient commits or threatens to commit a crime within our program or against our staff.

9. For court orders with legal mandates. We may disclose your SUD health information to comply with special Part 2 court orders and legal mandates (subpoena etc.) as described in Section E of this Patient Notice.

E. LEGAL PROCEEDINGS AND COURT ORDERS

We must follow certain procedures before using or sharing your SUD health information for investigations and legal proceedings.

1. We will not use or disclose your SUD health information records, or provide testimony about the content of the records, in any civil, administrative, criminal, or legislative proceedings against you unless you sign a specific consent form allowing the use or disclosure or a court orders the use or disclosure.

2. We may only use or disclose your SUD health information based on a court order after notice and an opportunity to hear is provided to you and/or the holder of the record (OHSU’s Part 2 Program), where required by 42 USC § 290dd-2 and 42 CFR Part 2.

3. We will not use or disclose your SUD health information unless a court order authorizing use or disclosure includes a subpoena or other similar legal mandate compelling our disclosure.

F. REDISCLOSURE UNDER HIPAA

When you consent to uses and disclosures for all future treatment, payment and health care operations activities, we may share your SUD health information with other substance use disorder treatment programs, doctors’ offices and other providers for those activities. If the person who receives your SUD health information is covered by HIPAA, they may use and share your information again without your consent for any purposes permitted by HIPAA. Your SUD health information still cannot be used in legal proceedings against you unless you consent or based on a Part 2 court order and legal mandate (subpoena, etc.).

G. OUR RESPONSIBILITIES

1. We are required by law to maintain the privacy and security of your SUD health information.

2. We must let you know promptly if a breach of your unsecured records occurs that may have compromised the privacy or security of your SUD health information.

3. We must follow the duties and privacy practices described in this notice and give you a copy of it.

5. We will not use or share your SUD health information other than as described in this notice, unless you give us written consent. You have the right to revoke that consent and must let us know in writing.

H. QUESTIONS

If you have questions about this Notice or its contents, you may ask your Part 2 Program staff members. You may also contact the OHSU Information Privacy and Security Office at privacy@ohsu.edu or (503) 494-0219.

I. CHANGES TO THE TERMS OF THIS NOTICE

We are required to follow the terms of this Notice. We reserve the right to change the terms of this notice, and those changes will apply to all SUD health information we have about you. The new notice will be available upon request from us or on our website.

J. EFFECTIVE DATE

This Notice is effective March 10, 2026 and amends in its entirety all prior OHSU 42 CFR Part 2 Patient Notices.

Notice of Availability of Language Assistance Services and Auxiliary Aids and Services

tel:503-494-8311English

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Deutsch (German)

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ភាសាខ្មែរ (Khmer)

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română (Romanian)

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