Effective Date: April 14, 2003, Revised March 4, 2021
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.
This is a Summary of key elements of the Privacy and Security Rules and not a complete or comprehensive guide to compliance. Additional information and details are located in Pediatric Specialists of Tulsa’s HIPAA Privacy and Security Manual. 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 at the office. 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 generated by Pediatric Specialists of Tulsa PLLC., whether made by Pediatric Specialists of Tulsa personnel or your personal doctor. This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information. WE ARE REQUIRED BY LAW TO:
• Maintain the privacy and security of your protected health information (PHI) and e-PHI.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We will mitigate any harm from unauthorized, impermissible or inadvertent disclosures of PHI. • We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
• We will maintain reasonable and appropriate administrative, technical and physical safeguards for protecting e-PHI. For more information see: www.hhs.gov/ocr/privacy/hipaa/...
CHANGES TO THIS NOTICE We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site. OTHER USES OF MEDICAL INFORMATION Other uses and disclosures of protected 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 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 by law to retain our records of the care that we provided to you. Thank you for allowing our office to provide you or your family member with quality care. We are making every effort to comply with the federal regulations and value your input. Please let us know if you have any comments or questions regarding this privacy policy. HOW WE MAY USE AND DISCLOSE INFORMATION ABOUT YOU The following categories describe different ways that we use and disclose protected 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 within one of the categories.
• For Treatment. We may use protected health information about you to provide you with medical treatment or services. We may disclose protected health information about you to doctors, physician assistants, nurses, technicians, medical students, pharmacists, or other professionals who are involved in treating you.
• Run Our Organization. We can use and share your health information to run our practice, improve your care and contact you when necessary.
• For Payment. We may use and disclose protected health 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.
• Appointment Reminders. We may use and disclose protected health information to contact you as a reminder that you have an appointment for treatment or medical care.
• Help With Public Health and Safety Issues. We can share health information about you for certain situations such as: Preventing disease; helping with product recalls; reporting adverse reactions to medications; reporting suspected abuse, neglect, or domestic violence; preventing or reducing a serious threat to anyone’s health or safety.
• 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.
• Research. We can use or share your information for health research.
• As Required By Law. We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy laws.
• Organ and Tissue Donation. If you are an organ donor, we may release protected medical information to organizations that handle organ procurement.
• Workers’ Compensation. We can use or share health information about you: for workers’ compensation claims; for law enforcement official; with health oversight agencies for activities authorized by law; for special government functions such as military, national security and presidential protective services.
• 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.
• Law Enforcement. We may release protected health information if asked to do so 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 the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement; About a death we believe may be the result of criminal conduct; About criminal conduct at our practice; 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.
• Medical Examiners and Funeral Directors. We can share health information with a coroner, medical examiner, or funeral director when an individual dies. • 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.
YOU’RE 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 can ask to see or get an electronic or paper copy of your medical record and other health information we have about you.
• We will provide a copy or summary of your health information, usually within 30 days of your request. we may charge a fee for the cost of copying, mailing or other supplies associated with you request. (By Oklahoma statute, we may charge you $0.50 per page for copies, plus our postage costs. If your record contains any item that requires a photographic process to copy, such as an x-ray or photograph, we may charge you up to $5.00 per image).
• Right to As Us to Correct Your Medical Record. You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. We may say “no” to your request, but we’ll tell you why in writing within 60 days.
• Right to an Accounting of Disclosures. You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
• Right to Request to Limit the Information We Share. You can ask us not to use or share certain health information for treatment, payment, or our operations. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment of our operations with your health insurer. We will say “yes” unless a law requires us to share that information. • Request Confidential Communications. You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests.
• Get a Copy of This Privacy Notice. You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
• Choose Someone to Act For You. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.
• File a Complaint. You can complain if you feel we have violated your rights by contacting our privacy officer. You can 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 www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint. YOUR CHOICES REGARDING HOW WE USE AND SHARE CERTAIN HEALTH INFORMATION: If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
• In these cases, you have both the right and choice to tell us to: Share information with your family, close friends, or others involved in your care; Share information in a disaster relieve situation; Include your information in a hospital directory. If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
• In these cases we NEVER share your information unless you give us written permission: Marketing purposes; sale of your information; most sharing of psychotherapy notes.
• In the case of fundraising: We may contact you for fundraising efforts, but you can tell us not to contact you again.