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Dr. Charles McBride

Dr. Shaina Sullivan


12370 SW First Street
Beaverton OR 97005

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503-644-3614 – Call or Text
833-990-0102 – Fax

Dr. Charles McBride

Dr. Shaina Sullivan




This Office is required by law to provide you with this Notice so that you will understand how we may use or share your information from your Designated Record Set. The Designated Record Set includes financial and health information referred to in this Notice as “Protected Health Information” (“PHI”) or simply “health information.” We are required to adhere to the terms outlined in this Notice. If you have any questions about this Notice, please contact the office’s Privacy Officer, Dr. Charles McBride.


Each time you are examined at our Office, a record of your visit is made containing health and financial information. Typically, this record contains information about your condition, the treatment we provide and payment for the treatment. We may use and/or disclose this information to:

  • Plan your care and treatment
  • Communicate with other health professionals involved in your care
  • Document the care you receive
  • Educate health professionals
  • Provide information for medical research
  • Provide information to public health officials
  • Evaluate and improve the care we provide
  • Obtain payment for the care we provide

Understanding what is in your record and how your health information is used helps you to:

  • Ensure it is accurate
  • Better understand who may access your health information
  • Make more informed decisions when authorizing disclosure to others



The following categories describe the ways that we use and disclose health information. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall into one of the categories.

  • For Treatment. We may use or disclose health information about you to provide you with medical treatment. We may disclose health information about you to doctors, nurses, therapists or other Office personnel who are involved in taking care of you at an Office. For example, a doctor treating you for an infection may need to know if you have diabetes because diabetes may slow the healing process. Different departments of an Office also may share health information about you in order to coordinate your care and provide you medication, lab work and special tests. We may also disclose health information about you to people outside the Office who may be involved in your medical care after you leave an Office. This may include family members, or visiting nurses to provide care in your home.
  • For Payment. We may use and disclose health information about you so that the treatment and services you receive at an Office may be billed to you, an insurance company or a third party. For example, in order to be paid, we may need to share information with your health plan about services provided to you. 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 cover the treatment.
  • For Health Care Operations. We may use and disclose health information about you for our day-to-day health care operations. This is necessary to ensure that all patients receive quality care. For example, we may use health information for quality assessment and improvement activities and for developing and evaluating clinical protocols. We may also combine health information about many patients to help determine what additional services should offer, what services should be discontinued, and whether certain new treatments are effective. Health information about you may be used for business development and planning, cost management analyses, insurance claims management, risk management activities, and in developing and testing information systems and programs. We may also use and disclose information for professional review, performance evaluation, and for training programs. Other aspects of health care operations that may require use and disclosure of your health information include accreditation, certification, licensing and credentialing activities, review and auditing, including compliance reviews, medical reviews, legal services and compliance programs. Your health information may be used and disclosed for the business management and general activities of the Office including resolution of internal grievances, customer service and due diligence in connection with a sale or transfer of the Office. In limited circumstances, we may disclose your health information to another entity subject to HIPAA for its own health care operations. We may remove information that identifies you so that the health information may be used to study health care and health care delivery without learning the identities of patients. We may disclose your age, birth date and general information about you in the Office newsletter, on activities calendars, and to entities in the community that wish to acknowledge your birthday or commemorate your achievements on special occasions.



  • Business Associates. There are some services provided in our Office through contracts with business associates. Examples include medical directors, outside attorneys and a copy service we use when making copies of your health record. When these services are contracted, we may disclose your health information so that they can perform the job we’ve asked them to do and bill you or your third-party payer for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information.
  • Providers. Many services provided to you, as part of your care at our Office, are offered by participants in one of our organized healthcare arrangements. These participants include a variety of providers such as physicians (e.g., MD, DO, Podiatrist, Dentist, Optometrist), and assistants.
  • Treatment Alternatives. We may use and disclose health information to tell you about possible treatment options or alternatives that may be of interest to you.
  • Health-Related Benefits and Services and Reminders. We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
  • Payment. We may use and disclose Health Information so that we may bill and receive payment from you, an insurance company, or a third party for the treatment and services you received. For example, we may give your health plan information so that they will pay for your treatment. However, if you pay for your services yourself (e.g. out-of-pocket and without any third party contribution or billing), we will not disclose Health Information to a health plan if you instruct us to not do so.
  • Fundraising/Marketing Activities. Health Information may be used for fundraising communications, but you have the right to opt-out of receiving such communications. Except for the exceptions detailed above, uses and disclosures of Health Information for marketing purposes, as well as disclosures that constitute a sale of Health Information, require your authorization if we receive any financial remuneration from a third party in exchange for making the communication, and we must advise you that we are receiving remuneration.
  • Individuals Involved in Your Care or Payment for Your Care. Unless you object, we may disclose health information about you to a friend or family member who is involved in your care. We may also give information to someone who helps pay for your care.
  • As Required By Law. We will disclose health information about you when required to do so by federal, state or local law.
  • To Avert a Serious Threat to Health or Safety. We may use and disclose health information about you to prevent a serious threat to your health and safety or the health and safety of the public or another person. We would do this only to help prevent the threat.
  • Military and Veterans. If you are a member of the armed forces, we may disclose health information about you as required by military authorities. We may also disclose health information about foreign military personnel to the appropriate foreign military authority.
  • Research. Under certain circumstances, we may use and disclose health information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one treatment to those who received another, for the same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of health information, trying to balance the research needs with patient=s need for privacy of their health information. Before we use or disclose health information for research, the project will have been approved through this research approval process. We may, however, disclose health information about you to people preparing to conduct a research project so long as the health information they review does not leave the Office.
  • Workers’ Compensation. We may disclose health information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
  • Reporting Federal and state laws may require or permit the Office to disclose certain health information related to the following:
    • Public Health Risks. We may disclose health information about you for public health purposes, including:
      • Prevention or control of disease, injury or disability;
      • Reporting child abuse or neglect;
      • Reporting reactions to medications or problems with products;
      • Notifying people of recalls of products;
      • Notifying a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease;
      • Notifying the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
    • Health Oversight Activities. We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities may include audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
    • Judicial and Administrative Proceedings: If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
    • Reporting Abuse, Neglect or Domestic Violence: Notifying the appropriate government agency if we believe a patient has been the victim of abuse, neglect or domestic violence.
  • Law Enforcement. We may disclose health information when requested by a law enforcement official:
    • In response to a court order, subpoena, warrant, summons or similar process;
    • To identify or locate a suspect, fugitive, material witness, or missing person;
    • About you, the victim of a crime if, under certain limited circumstances, we are unable to obtain your agreement;
    • About criminal conduct at the Office; and
    • In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.
    • National Security and Intelligence Activities. We may disclose health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
    • Correctional Institution: Should you be an inmate of a correctional institution, we may disclose to the institution or its agents health information necessary for your health and the health and safety of others.


Other uses and disclosures of health information not covered by this Notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.



Although your health record is the property of the Office, the information belongs to you. You have the following rights regarding your health information:

  • Right to Inspect and Copy. With some exceptions, you have the right to review and copy your information. You must submit your request in writing to Charles McBride, OD. In accord with applicable law, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.
  • Right to Amend. If you feel that health information in your record is incorrect or incomplete, you may ask us to amend the information. You have this right for as long as the information is kept by or for the Office. You must submit your request in writing to Charles McBride, OD. In addition, you must provide a reason for your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
    • Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
    • Is not part of the health information kept by or for the Office; or
    • Is accurate and complete.
  • Right to an Accounting of Disclosures. You have the right to request an “accounting of disclosures”. This is a list of certain disclosures we made of your health information, other than those made for purposes such as treatment, payment, or health care operations. You must submit your request in writing to Charles McBride, OD. Your request must state a time period which may not be longer than six years from the date the request is submitted and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper or electronically). The first list you request within a twelve month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
  • Right to Request Restrictions. You have the right to request a restriction or limitation on the health information we use or disclose about you. For example, you may request that we limit the health information we disclose to someone who is involved in your care or the payment for your care. You could ask that we not use or disclose information about a procedure you had to a family member or friend. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. You must submit your request in writing to our Privacy Officer, Dr. Charles McBride. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.
  • Right to Request Alternate Communications. You have the right to request that we communicate with you about medical matters in a confidential manner or at a specific location. For example, you may ask that we only contact you via mail to a post office box. You must submit your request in writing to Charles McBride, OD. We will not ask you the reason for your request. Your request must specify how or where you wish to be contacted. We will accommodate all reasonable requests.
  • Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice of Privacy Practices even if you agreed to receive the Notice electronically. You may ask for a copy of this Notice at any time and may obtain a copy at our website, To obtain a paper copy of this Notice contact our office at 503-644-3614.
  • Right to Electronic Records. You have the right to receive a copy of your electronic health records in electronic form.
  • Right to Breach Notification. You have the right to be notified if there is a Breach of privacy such that your Health Information is disclosed or used improperly or in an unsecured way.



I am responsible for the full payment of patient responsible charges at the time of service, including any health plan related copayments, coinsurances, deductibles, as well as charges not covered by or not paid for by my health plan. Fees for professional services and materials are not refundable.

McBride Optometrists is an in-network provider for many health and vision plans. However, plan participation is subject to change. While we do our best to inform you of insurance limitations and co-pays before your examination, it is ultimately your responsibility to verify coverage with your insurer.

Patients with in-network insurance:
I agree to assign medical benefits paid by my insurer(s) to McBride Optometrists for application to my bill. I further agree to pay all charges not covered under my policy or those charges that are my responsibility. I also acknowledge and authorize McBride Optometrists to use and disclose my health information to facilitate payment for the services I am receiving.

Due to policy provisions in our contract with your insurance carrier, we are obligated to collect all patient responsibility balances. If your insurance policy has provisions such as deductibles, co-insurance or co-payments please note that these are provisions that have been agreed to between you and your insurance carrier. We cannot legally discount fees after their submission on your behalf to your insurance carrier. In addition, if we are in your insurance carrier’s network of providers, we have additional contractual obligations to collect the balances as outlined by your insurance carrier. Writing off patient responsibility balances could jeopardize our contract with your insurance carrier.

Additionally, for those Medicare patients that may have any medical services that are eligible under Medicare, we are legally obligated to collect the patient responsibility for co-insurance, co-payment or deductible under the terms of the anti-kickback laws.

We sincerely regret if any of these regulatory provisions cause you any inconvenience, but we must be bound by all provisions of insurance policy and federal law. Please feel free to let us know if you have any questions or if you require assistance to fully understand these provisions.

Patients with out-of-network insurance:
If you choose to receive services from McBride Optometrists and he is an out-of-network provider for your health plan, Oregon law requires us to advise you that you will be financially responsible for coinsurance, copayments or other out-of-pocket expenses attributable to choosing an out of-network provider. We strongly suggest that you contact your insurance provider before your visit to ensure that you understand the nature and amounts of any out-of-network fees and costs that you might incur.
I understand that I have the right to choose an in-network provider and that McBride Optometrists is not or may not be an in-network provider for my insurance plan.
I understand that I will be responsible for payment of any coinsurance, copayments or other out-of-pocket expenses attributable to choosing an out of-network provider and that it is my responsibility to obtain the information as to the nature and amount of coverage I have for my treatment with McBride Optometrists as an out of network provider.
I am responsible for the full payment of patient responsible charges at the time of service.


We reserve the right to change this Notice. We reserve the right 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. We will post a copy of the current Notice in the Office and on the website. The Notice will specify the effective date on the first page, in the top right-hand corner. In addition, if material changes are made to this Notice, the Notice will contain an effective date for the revisions and copies can be obtained by contacting the Office administrator.


If you believe your privacy rights have been violated, you may file a complaint with the Office or with the Secretary of the Department of Health and Human Services. To file a complaint with the Office, contact Dr. Charles McBride. All complaints must be submitted in writing. You will not be penalized for filing a complaint.


Note: If you would like to download a PDF  please click here.