• As required by the Privacy Regulations
• Created as a Result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
• Effective Date of this Notice: April 14, 2003

This notice describes how health information about you (as a patient of this practice) may be used and disclosed, and how you can get access to this information. Please review this notice carefull.

Our Duty to Safeguard Your Protected Health Information
Individually identifiable information about your past, present, or future health or condition, the provision of health care to you, or payment for the health care is considered “Protected Health Information” (PHI). We are required to extend certain protections to your PHI, and to give you this Notice about our privacy practices that explains how, when and why we may use or disclose your PHI. Except in specified circumstances, we must use or disclose only the minimum necessary PHI to accomplish the intended purpose of the use or disclosure.

We are required to follow the privacy practices described in this Notice, though we reserve the right to change our privacy practices and the terms of this Notice at any time. You may request a copy of the new notice from the Clinic you visit or the Compliance Office at 2401 Southwest Boulevard in Tulsa, Oklahoma.

How We May Use and Disclose Your Protected Health Information
We use and disclose PHI for a variety of reasons. We have a limited right to use and/or disclosure of your PHI for purposes of:

• treatment
• payment
• our health care operations

For uses beyond that, we must have your written authorization unless the law permits or requires us to make the use or disclosure without your authorization.

If we disclose your PHI to an outside entity in order for that entity to perform a function on our behalf, we must have in place an agreement from the outside entity that it will extend the same degree of privacy protection to your information that we must apply to your PHI.

However, the law provides that we are permitted to make some uses/disclosures without your consent or authorization. Oklahoma law requires that we inform you that the information used or disclosed may include records which indicate the presence of a communicable or venereal disease which may include, but are not limited to:

• hepatitis
• syphilis
• gonorrhea
• Human Immunodeficiency Virus (HIV)
• Acquired Immune Deficiency Syndrome (AIDS)

Any use or disclosure also may include mental health or other sensitive information.

The following offers more description and some examples of our potential uses/disclosures of your PHI.

1. Uses and Disclosures Relating to Treatment, Payment, or Health Care Operations
   Generally, we may use or disclose your PHI as follows:
   • For treatment: We may disclose your PHI to doctors, nurses, and other health care personnel who are involved in providing your health care. For example, your PHI will be shared among members of your treatment team or with our laboratory staff. Your PHI may also be shared with outside entities performing ancillary services relating to your treatment, such as x-rays, or for consultation purposes in provision or coordination of your care.

      

   • To obtain payment: We may use/disclose your PHI in order to bill and collect payment for your health care services. We may release information to third parties for collection purposes. For example, we may contact your employer to verify:
     • employment status
     • release portions of your PHI to the Medicaid program
     • a private insurer to get paid for services that we delivered to you.

      

   • For health care operations: We may use/disclose your PHI in the course of operating our clinics. For example, we may disclose your PHI to our accountant or attorney for audit purposes. Since we are an integrated system, we may disclose your PHI to designated staff in our other facilities or offices for similar purposes. Release of your PHI to state agencies might also be necessary to determine your eligibility for publicly funded services.

      

   • Appointment reminders: Unless you provide us with alternative instructions, we may send appointment reminders and other similar materials to your home, or notify you of appointments by phone.

      

2. Uses and Disclosures Requiring Authorization
   For uses and disclosures beyond treatment, payment and operations purposes we are required to have your written authorization, unless the use or disclosure falls within one of the exceptions described below. Authorizations can be revoked at any time to stop future uses/disclosures except to the extent that we have already undertaken an action in reliance upon your authorization.

    

3. Uses and Disclosures of PHI not requiring consent or authorization
   The law provides that we may use/disclose your PHI without consent or authorization in the following circumstances:
   • When required by law: We may disclose PHI when a law requires that we report information about suspected abuse, neglect or domestic violence, or relating to suspected criminal activity, or in response to a court order. We must also disclose PHI to authorities that monitor compliance with these privacy requirements.

      

   • For public health activities: We may disclose PHI when we are required to collect information about disease or injury, or to report vital statistics to the public health authority. Oklahoma law requires us to report, among other things, the following items:
     • Tumors
     • Birth Defects
     • Cases of communicable disease
     • Infant eye infections
     • Infants born exposed to alcohol and other harmfulsubstances
     • Abortions

      

   • For health oversight activities: We may disclose PHI to our central office, or another agency responsible for monitoring the health care system for such purposes as reporting or investigation of unusual incidents, and monitoring of the Medicaid program.

      

   • Relating to decedents: We may disclose PHI relating to an individual’s death to coroners, medical examiners or funeral directors, and to organ procurement organizations relating to organ, eye, or tissue donations or transplants.

      

   • For research purposes: In certain circumstances, and under supervision of a privacy board, we may disclose PHI to our research staff and their designees in order to assist medical/psychiatric research.

      

   • To avert threat to health or safety: In order to avoid a serious threat to health or safety, we may disclose PHI as necessary to law enforcement or other persons who can reasonably prevent or lessen the threat of harm.

      

   • For specific government functions: We may disclose PHI of military personnel and veterans in certain situations, to correctional facilities in certain situations, to government benefit programs relating to eligibility and enrollment, and for national security reasons, such as protection of the President.

      

   • For Worker's Compensation purposes: We may disclose PHI in relation to workers’ compensation programs, established by law, that provide benefits for work-related injuries or illnesses.

    

4. Uses and Disclosures of PHI from Alcohol and Other Drug Records Not Requiring Consent or Authorization
   The law provides that we may use/disclose your PHI from alcohol and other drug records without consent or authorization in the following circumstances:
   • When required by law: We may use/disclose PHI when a law requires that we report information about suspected child abuse and neglect, or when a crime has been committed on the premises or against personnel, or in response to a court order.

      

   • Relating to decedents: We may disclose PHI relating to an individual’s death if state or federal law requires the information for collection of vital statistics or inquiry into cause of death.

      

   • For research, audit or evaluation purposes: In certain circumstances, we may disclose PHI for research, audit or evaluation purposes.

      

   • To avert threat to health or safety: In order to avoid a serious threat to health or safety, we may disclose PHI as necessary to law enforcement when a threat is made to commit a crime on the premises or against personnel.

    

5. Uses and Disclosures Requiring You to have an Opportunity to Object
   In the following situations, we may disclose a limited amount of your PHI if we inform you about the disclosure in advance and you do not object, as long as the disclosure is not otherwise prohibited by law.
   • Patient Directories: Your name, location, and general condition my be disclosed to callers or visitors who ask for you by name. Additionally, your religious affiliation may be shared with clergy.

      

   • To families, friends or others involved in your care: We may share with these people information directly related to their involvement in your care, or payment for your care. We may also share PHI with these people to notify them about your location, general condition, or death.

    

6. Your Rights Regarding Your Protected Health Information
   You have the following rights relating to your protected health information:
   • To request restrictions on uses/disclosures: You have the right to ask that we limit how we use or disclose your PHI. We will consider your request, but are not legally bound to agree to the restriction. To the extent that we do agree to any restrictions on our use/disclosure of your PHI, we will put the agreement in writing and abide by it except in emergency situations. We cannot agree to limit uses/disclosures that are required by law.

      

   • To choose how we contact you: You have the right to ask that we send your information to an alternative address or by an alternative means. We must agree to your request as long as it is reasonably easy for us to do so.

      

   • To inspect and request a copy of your PHI: Unless your access to your records is restricted for clear and documented treatment reasons, you have a right to see your protected health information upon your written request. We will respond to your request within 30 days. If we deny your access, we will give you written reasons for the denial and explain any right to have the denial reviewed. If you want copies of your PHI, a charge for copying may be imposed, depending on your circumstances. You have a right to choose what portions of your information you want copied and to have prior information on the cost of copying.

      

   • To request amendment of your PHI: If you believe that there is a mistake or missing information in our record of your PHI, you may request, in writing, that we correct or add to the record. We will respond within 60 days of receiving your request. We may deny the request if we determine that the PHI is
     1. correct and complete
     2. not created by us and/or not part of our records
     3. not permitted to be disclosed.

     Any denial will state the reasons for denial and explain your rights to have the request and denial, along with any statement in response that you provide, appended to your PHI. If we approve the request for amendment, we will change the PHI and so inform you, and tell others that need to know about the change in PHI.

   • To find out what disclosures have been made: You have a right to get a list of when, to whom, for what purpose, and what content of your PHI has been released other than instances of disclosure for treatment, payment, and operations; to you, your family, or the facility directory; or pursuant to your written authorization. The list also will not include any disclosures made for national security purposes, to law enforcement officials or correctional facilities, or disclosures made before April 14, 2003. We will respond to your written request for such a list within 60 days of receiving it. Your request can relate to disclosures going as far back as six years. There will be no charge for up to one such list each year. There may be a charge for more frequent requests.

      

   • To receive this notice: You have a right to receive a paper copy of this Notice and/or an electronic copy by email upon request.

    

7. How to Complain about Our Privacy Practices
   If you have questions about this Notice or any complaints about our privacy practices, please contact the Compliance Office listed below. If you think we may have violated your privacy rights, or you disagree with a decision we made about access to your PHI, you may request information or file a complaint by contacting:

   OSU Center for Health Sciences
   Privacy Complaint Office
   Attention: Privacy Officer
   1111 West 17th Street
   Tulsa, OK 74107
   918-699-4501
   privacy@chs.okstate.edu

   You also may file a written complaint with the Secretary of the U.S. Department of Health and Human Services at 200 Independence Avenue SW, Washington D.C., 20201 or call 1-877-696-6775. We will take no retaliatory action against you if you make such complaints.