THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN
GET ACCESS TO THIS INFORMATIONPLEASE REVIEW IT CAREFULLY
THE HEALTH INSURANCE PORTABILITY & ACCOUNTABILITY ACT OF 1996 “HIPPA” IS A FEDERAL PROGRAM THAT REQUIRES THAT ALLMEDICAL RECORDS AND OTHER INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION USED OR DISCLOSED BY US IN ANY FORM,WHETHER ELECTRONICALLY, ON PAPER, OR ORALLY, ARE KEPT PROPERLY CONFIDENTIAL. THIS ACT GIVES YOU, THE PATIENT,SIGNIFICANT NEW RIGHTS TO UNDERSTAND AND CONTROL HOW YOUR HEALTH INFORMATION IS USED. HIPPA PROVIDESPENALTIES FOR COVERED ENTITIES THAT MISUSE PERSONAL HEALTH INFORMATION.AS REQUIRED BY HIPPA, WE HAVE PREPARED THIS EXPLANATION OF HOW WE ARE REQUIRED TO MAINTAIN THE PRIVACY OF YOURHEALTH INFORMATION AND HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION.WE MAY USE AND DISCLOSE YOUR MEDICAL RECORDS ONLY FOR EACH OF THE FOLLOWING PURPOSES: TREATMENT, PAYMENTAND HEALTH CARE OPERATIONS.
• TREATMENT MEANS PROVIDING, COORDINATING OR MANAGING HEALTH CARE AND RELATED SERVICES BY ONE OR MOREHEALTH CARE PROVIDERS.
• PAYMENT MEANS SUCH ACTIVITIES AS OBTAINING REIMBURSEMENT FOR SERVICES, CONFIRMING COVERAGE, BILLING ORCOLLECTION ACTIVITIES, AND UTILIZATION REVIEW. AN EXAMPLE OF THIS WOULD BE SENDING A BILL FOR YOUR VISIT TO YOURINSURANCE COMPANY FOR PAYMENT.
• HEALTH CARE OPERATIONS INCLUDE THE BUSINESS ASPECTS OF RUNNING OUR PRACTICE, SUCH AS CONDUCTING QUALITYASSESSMENT AND IMPROVEMENT ACTIVITIES, AUDITING FUNCTIONS, COST­MANAGEMENT ANALYSIS AND CUSTOMER SERVICE. ANEXAMPLE WOULD BE AN INTERNAL QUALITY ASSESSMENT REVIEW.WE MAY ALSO CREATE AND DISTRIBUTE DE-IDENTIFIED HEALTH INFORMATION BY REMOVING ALL REFERENCES TO INDIVIDUALLYIDENTIFIABLE INFORMATION.WE MAY CONTACT YOU TO PROVIDE APPOINTMENT REMINDERS OR INFORMATION ABOUT TREATMENT ALTERNATIVES OR OTHERHEALTH-RELATED BENEFITS AND SERVICES THAT MAY BE OF INTEREST TO YOU.ANY OTHER USES AND DISCLOSURES WILL BE MADE ONLY WITH YOUR WRITTEN AUTHORIZATION. YOU MAY REVOKE SUCHAUTHORIZATION IN WRITING AND WE ARE REQUIRED TO HONOR AND ABIDE BY THAT WRITTEN REQUEST, EXCEPT TO THE EXTENTTHAT WE HAVE ALREADY TAKEN ACTIONS RELYING ON YOUR AUTHORIZATION.YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PROTECTED HEALTH INFORMATION, WHICH YOU CAN EXERCISE BYPRESENTING A WRITTEN REQUEST TO THE PRIVACY OFFICER.
• THE RIGHT TO REQUEST RESTRICTIONS ON CERTAIN USES AND DISCLOSURES OF PROTECTED HEALTHINFORMATION, INCLUDING THOSE RELATED TO DISCLOSURES TO FAMILY MEMBERS, OTHER RELATIVES,CLOSE PERSONAL FRIENDS, OR ANY OTHER PERSON IDENTIFIED BY YOU. WE ARE, HOWEVER, NOT REQUIRED TO AGREE TO AREQUESTED RESTRICTION. IF WE DO AGREE TO A RESTRICTION, WE MUST ABIDE BY IT
NOTICE OF PRIVACY PRACTICESPage 2UNLESS YOU AGREE IN WRITING TO REMOVE IT.
• THE RIGHT TO REASONABLE REQUESTS TO RECEIVE CONFIDENTIAL COMMUNICATIONS OF PROTECTEDHEALTH INFORMATION FROM US BY ALTERNATIVE MEANS OR AT ALTERNATIVE LOCATIONS.
• THE RIGHT TO INSPECT AND COPY YOUR PROTECTED HEALTH INFORMATION.
• THE RIGHT TO AMEND YOUR PROTECTED HEALTH INFORMATION.
• THE RIGHT TO BE NOTIFIED UPON A BREACH OF ANY OF YOUR UNSECURED PROTECTED HEALTHINFORMATION.
• THE RIGHT TO RECEIVE AN ACCOUNTING OF DISCLOSURES OF PROTECTED HEALTH INFORMATION.
• THE RIGHT TO OBTAIN A PAPER/ ELECTRONIC COPY OF THIS NOTICE FROM US UPON REQUEST.OUT-OF-POCKET-PAYMENTS:IF YOU PAID OUT-OF-POCKET {OR IN OTHER WORDS, YOU HAVE REQUESTED THAT WE NOT BILL YOUR HEALTH PLAN) IN FULL FOR ASPECIFIC ITEM OR SERVICE, YOU HAVE THE RIGHT TO ASK THAT YOUR PROTECTED HEAL THINFORMATION WITH RESPECT TO THAT ITEM OR SERVICE NOT BE DISCLOSED TO A HEALTH PLAN FOR PURPOSES OF PAYMENT ORHEALTH CARE OPERATIONS, AND WE WILL HONOR THAT REQUEST.WE ARE REQUIRED BY LAW TO MAINTAIN THE PRIVACY OF YOUR PROTECTED HEALTH INFORMATION AND TOPROVIDE YOU WITH NOTICE OF OUR LEGAL DUTIES AND PRIVACY PRACTICES WITH RESPECT TO PROTECTED HEALTH INFORMATION.THIS NOTICE IS EFFECTIVE AS OF JANUARY 1, 2017 AND WE ARE REQUIRED TO ABIDE BY THE TERMS OF THE NOTICE OF PRIVACYPRACTICES CURRENTLY IN EFFECT. WE RESERVE THE RIGHT TO CHANGE THE TERMS OF OUR NOTICE OFPRIVACY PRACTICES AND TO MAKE THE NEW NOTICE PROVISIONS EFFECTIVE FOR ALL PROTECTED HEAL TH THAT WE MAINTAIN. WEWILL POST AND YOU MAY REQUEST A WRITTEN COPY OF A REVISED NOTICE OF PRIVACY PRACTICES FROM THIS OFFICE.YOU HAVE RECOURSE IF YOU FEEL THAT YOUR PRIVACY PROTECTIONS HAVE BEEN VIOLATED. YOU HAVE THE RIGHT TO FILE AWRITTEN COMPLAINT WITH US AT THE ADDRESS BELOW, OR WITH THE DEPARTMENT OF HEALTH &HUMAN SERVICES, OFFICE OF CIVIL RIGHTS, ABOUT VIOLATIONS OF THE PROVISIONS OF THIS NOTICE OR THEPOLICIES AND PROCEDURES OF OUR OFFICE. WE WILL PROVIDE YOU WITH THE ADDRESS TO FILE YOUR COMPLAINT WITH THE U.S.DEPARTMENT OF HEALTH AND HUMAN SERVICES UPON REQUEST. WE SUPPORT YOUR RIGHT TO THE PRIVACY OF YOUR HEALTHINFORMATION. WE WILL NOT RETALIATE AGAINST YOU FOR FILING A COMPLAINT.By Oklahoma law, we are required to notify you … that the information authorized for release may include records which mayindicate the presence of a communicable or venereal disease which may include, but are not limited to, diseases such ashepatitis, syphilis, gonorrhea and the human immunodeficiency virus, also known as AcquiredImmune Deficiency Syndrome (AIDS).PLEASE CONTACT US FOR MORE INFORMATIONPremier Orthopedic Specialists of Tulsa2448 E. 81st St. Suite 1520Tulsa, OK 74137Phone: 918-900-2520Fax: 918-900-2521