top
Policies » Notice of Privacy Practice

Notice of Privacy Practice

Effective September 25, 2006

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 of Privacy Practices, please contact our Privacy Officer at (918)274-9700.

This Notice of Privacy Practices describes how Owasso Pediatric and Adolescent Medicine (OPAM) may use and disclose your health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. The notice also explains your rights to access and amend your health information and receive an accounting of disclosures of this information. Your individually identifiable health information is information that may identify you and that relates to your past, present or future physical or mental health or condition; health care services you receive; or payment for your care.

OPAM will create a record of the services we provide you, and this record will include your health information. OPAM needs to maintain this information to ensure that you receive quality care and to meet certain legal requirements related to providing you care. We understand that your health information is personal, and we are committed to protecting your privacy and ensuring that your medical information is not used inappropriately.

OPAM is required by law to:

  • maintain the confidentiality of your medical information;
  • provide you a Notice of Privacy Practices that outlines our legal duties for protecting the privacy of your medical information and that explains your rights to have your medical information protected; and
  • abide by the terms of the Notice of Privacy Practice.

USES AND DISCLOSURES BASED ON PRIVACY REGULATIONS

The federal privacy regulations authorize the use and disclosure of protected health information for treatment, payment, and health care operations.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

The following categories describe the ways that OPAM may use and disclose your protected health information. We have explained each type of disclosure and given some examples of the uses and disclosures of information that fit into these classifications. Not every possible use or disclosure in a category will be listed, but every use or disclosure of health information will correspond to one of these categories.

  • For Treatment -- OPAM will use your health information to provide you medical treatment or related services. We will share your health information with others in the practice involved in your care. For example, your health information will be disclosed to the nurses who participate in your care. We might also disclose your protected health information to another OPAM physician for the purpose of a consultation or to other health care providers who request such information for purposes of providing medical treatment to you.
  • For Payment -- OPAM will use and disclose your health information in order to receive payment from you, an insurance company or a third party for the services provided to you. We may contact you for additional information in order to process your claim. We may share your health information with payers to obtain prior approval authorization, and we may contact you, your insurance company or your employee benefit manager if your claim is rejected or to resolve issues regarding your insurance benefits. We also may provide information about you to other health care providers to assist them in obtaining payment for treatment and service provided to you by that provider.
  • For Health Care Operations -- OPAM may use or disclose your health information for our internal operations. For example, we may use your health information for quality assessment activities, training of medical students, necessary licensing, and for other essential activities of the practice.

We may ask you to sign your name to a sign-in sheet at the registration desk and we may call your name in the waiting room when we call you for your appointment.

We may disclose medical information about you to another health care provider or health plan with which you also have had a relationship for purposes of that provider or plan's operations.

OPAM will disclose your protected health information with third party business associates that perform various services for OPAM. In these cases, we will enter into a written agreement with the business associate to ensure that the business associate protects the privacy of your protected health information.

OTHER USES AND DISCLOSURES

  • Appointment Reminders -- We may use your health information to send you a reminder of an appointment. We may call you at the phone number you provide and leave a message on your answering machine or with whomever answers the phone identifying OPAM and asking that you return our call unless you tell us otherwise.
  • Treatment Alternatives and Health-Related Benefits and Services -- OPAM may use your health information to inform you of services or programs that we believe would be beneficial to you. We may call or mail you information about these services or goods. For example, we may contact you to make you aware of new products; supply product information; or alert you to a new patient assistance program that may be available to you. At no time will your health information be released to third parties to allow them to communicate with you directly regarding new products or services, unless you have authorized such disclosure.

If you do not wish to receive these materials, you may contact our office to request that these materials not be sent to you.

  • Other Information -- OPAM may use your health information in order to send you educational materials. If you do not wish to receive these materials, you may contact our office to request that these materials not be sent to you.
  • Individuals Involved in Your Care or Payment for Your Care -- OPAM may release your medical information, including information about your condition, to a friend or family member who is involved in your medical care or who helps pay for your care. We may also disclose medical information about you to disaster relief organizations so that your family can be notified about your condition, status, and location.
  • Emergency Situations -- We may use or disclose your health information in an emergency treatment situation to ensure that you receive quality care.
  • Research -- We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.
  • Communication Barriers -- We may use and disclose your protected health information if we determine that there is a communication barrier that prevents you from authorizing the use or disclosure of your health information but we conclude, using our professional judgment, that it is your intent to authorize such use or disclosure.
  • As Required By Law -- OPAM may disclose your medical information when required to do so by federal, state or local law.
  • To Avert a Serious Threat to Health or Safety -- OPAM may use and disclose your medical information if necessary to prevent serious harm to your health and safety or the health and safety of the public or another person. Any such use or disclosure would only be to an individual able to prevent the harm.
  • Organized Health Care Arrangement –- OPAM may use and disclose your medical information with other providers in an organized health care arrangement for purposes of treatment, payment, and health care operations. An organized health care arrangement includes independent physicians and clinicians, hospitals, and other contracted technicians who may provide care to you within a clinically integrated health care setting.

SPECIAL CIRCUMSTANCES

  • Public Health Risks -- OPAM may disclose information about you for a number of public health activities. These include disclosures:
    • to prevent or control disease, injury or disability;
    • to report deaths;
    • to report child abuse or neglect;
    • to report adverse events, product defects or problems; to track products; to notify patient of product recalls; and to conduct post-marketing surveillance as required by the Food and Drug Administration;
    • to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and
    • to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. This disclosure will be made only if you agree or to the extent required by law.
  • Health Oversight -- We may disclose health information for oversight 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.
  • Employers -- We may disclose medical information about you to your employer if we provide health care services to you at the request of your employer, and the health care services are provided either to conduct an evaluation relating to medical surveillance of the workplace or to evaluate whether you have a work-related illness. In such circumstances, we will give you written notice of such release of information to your employer at the time the health care services are provided. Any other disclosures to your employer will be made only if you execute a specific authorization for the release of that information to your employer.
  • Workers Compensation -- We may disclose information about you to workers compensation or similar programs. These programs provide benefits for work-related injuries or illnesses.
  • Law Enforcement -- We may disclose your health information to a law enforcement official for several different purposes:
    • to comply with a court order, warrant, subpoena, summons or other similar process;
    • to assist in identifying or locating 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 victim's agreement;
    • about a death if there is reason to believe it may be the result of criminal conduct;
    • about criminal conduct in our office;
    • to report a crime, the location of a crime, and the identity, description, and location of the perpetrator of such crime, in an emergency situation.
  • Lawsuits and disputes -- If you are involved in a lawsuit or dispute, we may disclose your health information in response to a court or administrative order. We may also release your health information to a party in the lawsuit, but only in response to a subpoena, discovery request or other lawful process and only if the party has made reasonable efforts to inform you of the request or secure an order protecting the requested information.
  • Organ and tissue donation -- If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank.
  • Coroners, Medical Examiners, and Funeral Directors -- We may release health information to a coroner or medical examiner to assist in identifying a deceased person or determining the cause of death. Health information may also be released to funeral directors to assist them in performing their duties.
  • National Security and Intelligence Activities and Protective Services -- We may release your health information to authorized federal officials for the conduct of intelligence, counterintelligence, and other national security activities. We may disclose your health information to authorized federal officials to facilitate protective services to the President and others, including foreign heads of state or to conduct special investigations.
  • Military and Veterans Activities -- If you are a member of the Armed Force, we may disclose your medical information to military command authorities. Medical information about foreign military personnel may be disclosed to appropriate foreign military authorities.
  • Inmates -- If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose your health information to those authorities to assist them in providing you health care, protecting your health and safety or the health and safety of others or for the safety and security of the correctional institution.
  • strong>Required Uses and Disclosures -- As required by the law, we must make disclosures to you and to the Secretary of Health and Human Services to determine our compliance with federal medical privacy regulations.
  • Other Uses of Medical Information -- Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written authorization. If you provide OPAM with authorization to use or disclose medical information about you, you may revoke that authorization, in writing, at any time. If this authorization is revoked, OPAM will no longer use or disclose medical information for the reasons covered by your written authorization. OPAM will be unable to recover any disclosures already made with your permission, and that we are required to retain in our records of the care that was provided to you.

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION

  • Right to Request Restrictions -- You have the right to request restrictions on the use and disclosure of your health information for treatment, payment, and health care operations. You may also request limits on the health information that is released to individuals, such as family members or friends, who are involved in your care or the payment for your care. For example, you could ask that we not use or disclose information about a surgery you had.

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.

For restrictions, you will be requested to complete a form to submit to our Privacy Officer. Include (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; (3) to whom you want the limits to apply, for example, disclosure to your spouse.

  • Right to Inspect and Copy -- You have a right to inspect and to obtain a copy of your medical record or the health information that is used by your health care providers to make decisions about your care. Billing information would generally be considered to be part of your medical record. However, you will not have access to information that is compiled in reasonable anticipation of, or use in, a civil, criminal or administrative action or proceeding.

To inspect and to obtain a copy of medical information that may be used to make decisions about your care, OPAM will require that you or your authorized representative submit an authorization form consistent with the requirements of the State of Oklahoma and the Privacy Regulations to our Privacy Officer. If you request a copy of the information, you may be charged a reasonable cost-based fee for the costs of copying, mailing, and for other supplies that are required to respond to your request. By statute in Oklahoma, we may charge you $1.00 for the first page and 50¢ per page thereafter, 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.

We will inform you when the records are ready or if we believe access should be limited. Access may be denied if the requested information contains psychotherapy notes, the information reveals the identity of a person who provided information under a promise of confidentiality, or the information is subject to the Clinical Laboratory Improvements Amendments of 1988. We can refuse to provide access to or copies of some information for other reasons. If we deny your request to review your medical record, you may appeal that denial. Another licensed health care professional chosen by OPAM will review your request and denial. The person conducting the review will not be the person who denied your request. OPAM will comply with the outcome of the review.

  • Right to Amend -- You have the right to request that we amend the information in your medical record, for as long as we keep your medical record. You will be requested to complete a form that includes the reason(s) for your request and submit it to our Privacy Officer.

We may deny your request if it is not in writing and does not include a reason to support the request. We may also deny your request if the information that you wish to amend:

  • was not created by OPAM;
  • is not part of the medical record kept by OPAM;
  • is not part of the information that you would be permitted to inspect or to obtain a copy; or
  • is complete and accurate.

If we deny your request to amend your record, you may still file a statement of disagreement with OPAM and we may in turn prepare a response to your statement of disagreement.

  • Right to Accounting of Disclosures -- You have the right to request an accounting of disclosures of your medical information for purposes except for treatment, payment, and health care operations. Certain disclosures, including those we made to you and to family members and friends involved in your care and those you authorize, will be excluded from the accounting. Your request must state a time period that may not be longer than six years and may not include dates before September 25th, 2006.

You will be requested to complete a form for an accounting of disclosures. The first accounting within a 12-month period will be provided to you free of charge. For additional accountings of disclosures provided to you during any 12-month period, we may charge you for the costs of preparing the accounting. We will notify you of the charges and you may withdraw or modify your request before any charges are incurred.

  • Right to Request Confidential Communications -- You may request that we communicate with you in a certain manner or at a certain location regarding the services you receive from OPAM. For example, you may request that we only contact you by mail and you may request that all correspondence be directed to your work address.

You will be requested to complete a form for confidential communications to submit to our Privacy Officer. You are not required to provide a reason for your request. We will honor all reasonable requests. Your request must specify how or where you wish to be contacted.

  • Right to a Paper Copy of This Notice -- You have the right to a paper copy of this notice, even if you have agreed to receive this notice electronically by visiting our website at www.owassopeds.net. You may also receive a copy of this notice at any time by contacting:

Privacy Officer

Owasso Pediatric and Adolescent Medicine

12455 East 100th Street North, Suite 300

wasso , OK 74055

918 274-9700

CHANGES TO THIS NOTICE

We reserve the right to change this notice. If we change the notice, we may make it effective for health information we already have, as well as for information about you that we receive in the future.

Any updates to the Notice of Privacy Practices will be mailed to you upon request, provided at your next visit, or obtained by visiting our website at www.owassopeds.net.

ACKNOWLEDGEMENT

We are required by law to make a good faith effort to provide you with our Notice of Privacy Practices and obtain such acknowledgement from you. However, your receipt of care and treatment from OPAM is not conditioned upon your providing the written acknowledgement.

COMPLAINTS

If you believe your health information has been used or disclosed improperly or your privacy rights have been violated, you may file a complaint in writing with:

Privacy Officer

Owasso Pediatric and Adolescent Medicine

12455 East 100th Street North, Suite 300

wasso , OK 74055

918 274-9700

You may file a complaint with the Secretary of the Department of Health and Human Services.

OPAM will not penalize you for filing a complaint.

bottom