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.
If you have any questions about this notice, please contact our patient representative.
WHO WILL FOLLOW THIS NOTICE:
This notice describes our office's practices and that of:
Any health care professional authorized to enter information into your file or record.
All employees, staff, and other personnel.
OUR PLEDGE REGARDING MEDICAL INFORMATION:
We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive in our practice. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care.
This notice will tell you about the ways in which we may use and disclose medical information about you. It also describes your rights and certain obligations we have regarding the use and disclosure of medical information.
We are required by law to:
make sure that medical information that identifies you is kept private;
give you this notice of our legal duties and privacy practices with respect to protected medical information about you; and follow the terms of the notice that is currently in effect.
HOW WE MAY USE AND DISCLOSE YOUR MEDICAL INFORMATION
The following categories describe different ways that we use and disclose protected medical information. For each category of uses or disclosures we will explain what we mean. 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 within one of the categories.
For Treatment: We may use protected medical information about you to provide you with medical treatment or services. We may disclose protected medical information about you to doctors, nurses, technicians, medical students, pharmacists, or other personnel who are involved in taking care of you. Different departments of our practice also may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work, and x-rays. We also may disclose protected medical information about you to people outside the practice who may be involved in your medical care, such as family members or others we use to provide services that are part of your care.
For Payment: We may use and disclose protected medical information about you so that the treatment and services you receive may be billed to and payment may be collected from you, an insurance company, or a third party. For example, we may need to give your health plan information about treatment you received so your health plan will pay us or reimburse you. We may also tell your health plan about a treatment you are going to receive in order to obtain prior approval or to determine whether your plan will cover the treatment. We also may use and disclose your information to obtain payment from third parties that may be responsible for such costs, such as family members. We may use your information to bill you directly for services and items.
Appointment Reminders: We may use and disclose protected medical information to contact you as a reminder that you have an appointment for treatment or medical care.
Treatment Alternatives: We may use and disclose protected medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
Health-Related Benefits and Services: We may use and disclose protected medical information to tell you about health-related benefits or services that may be of interest to you.
Individuals Involved In Your Care or Payment For Your Care: We may release protected medical information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. We may also tell your family or friends your condition. In addition, we may disclose protected medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status, and location.
Research: Our practice is involved in clinical research. Research nurses and others involved in medical research may have access to your personal medical record to help determine if you are eligible to participate in clinical research. If you do participate in clinical research programs, these people will obtain personal medical information from your records that is needed in the conduct of clinical research. All reasonable precautions shall be taken to protect the privacy and confidentiality of your personal medical information.
As Required By Law: We will disclose protected medical 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 protected medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
Organ and Tissue Donation: If you are an organ donor, we may release protected medical information to organizations that handle organ procurement or organ, eye, or tissue transplantation to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.
Military and Veterans: If you are a member of the armed forces, we may release protected medical information about you as required by military command authorities. We may also release protected medical information to a foreign military authority, if you are in their service.
Workers' Compensation: We may release protected medical information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness. Release of such information is controlled by state and/or federal law.
Public Health Risks: We may disclose protected medical information about you for public health activities. These activities generally include the following:
Health Oversight Activities: We may disclose protected medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, 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.
Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose protected medical 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.
Law Enforcement: We may release protected medical information if asked to do so by a law enforcement official:
Medical Examiners and Funeral Directors: We may release protected medical information to a medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release protected medical information about patients to funeral directors as necessary to carry out their duties.
National Security and Intelligence Activities: We may release protected medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
Protective Services for the President and Others: We may disclose protected information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.
Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release protected medical information about you to the correctional institution or law enforcement official. This release would be necessary (1) for this practice to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU.
You have the following rights regarding protected medical information we maintain about you:
Right to Inspect and Copy: You have the right to inspect and receive medical information that may be used to make decisions about your care. This includes medical and billing records, but does not include psychotherapy notes.
To inspect and/or receive copies of your medical information you must submit your request to the Medical Records Department. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies associated with your request. By statute in Oklahoma we may charge you $0.25 per page for copies, plus our postage costs.
Right to Amend: If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by our practice.
To request an amendment, your request must be made in writing and submitted to the Medical Records Department. In addition, you must provide a reason that supports your amendment 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:
Right to an Accounting of Disclosures: You have the right to request an “accounting of disclosures.” This is a list of the disclosures we have made of your medical information. To request this list or accounting of disclosures, you must submit your request in writing to the Medical Records Department. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003.
Right to Request Restrictions: You have the right to request a restriction or limitation on the protected medical information we use or disclose about you for treatment, payment or health care operations. However, we must receive your restrictions in writing before we have made such disclosures. Also, if you restrict our right to use your protected medical information for treatment, payment or health operations, we reserve the right to immediately withdraw our services from you and terminate the physician-patient relationship.
You also have the right to request a limit on the protected medical information we disclose about you to someone who is involved in your care or in the payment of your care, such as a family member or friend. For example, you could ask that we not use or disclose information about a surgery to your family. 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.
To request restrictions, you must make your request in writing to the Medical Records Department. In your request for restrictions, 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 Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work, or at home, or by mail, or by phone, or by e-mail.
To request confidential communications, you must make your request in writing to the Medical Records Department. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
Right to a Copy of This Notice: You have the right to a copy of this notice. You may ask us to give you a copy of this notice at any time.
You may obtain a copy of this notice at our Web site, www.injecttulsa.com.
CHANGES TO THIS NOTICE
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for protected medical 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 our office. The notice will contain on the first page, in the top right-hand corner, the effective date. In addition, each time you are in our office for treatment or health care services, we will offer you a copy of the current notice in effect.
If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. To file a complaint with our office, contact our patient representative at (918) 712-1767. All complaints must be submitted in writing.
You will not be penalized for filing a complaint.
OTHER USES OF MEDICAL INFORMATION
Other uses and disclosures of protected medical 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 protected medical 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 protected medical 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.