This is very important information regarding your medical information -- how it may be used, how it may be disclosed, and how you may access it.

Who will follow the terms of this notice:

• Any health care professional authorized to enter information into your file or record.
• All employees, staff, and personnel.

• 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 medical information about you.
• Follow the terms of the notice that is currently in effect.

1. 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, physician assistants, nurses, technicians, medical students, pharmacists, or other personnel who are involved in taking care of you at our office. We also me disclose protected medical information about you to people outside our practice who may be involved in your medical care such as family members, specialists, and their staff or hospital staff, or others we use to provide services that are part of your care. For example, we may need to find out the medications you were previously prescribed to allow for appropriate treatment. Or, the doctor may be required to order lab or x-rays. The facility that will process the test will need your protected health information for continuity of care.
   
   
2. 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 a procedure that you received at our office so that your health plan will pay us or reimburse you. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. We will obtain your consent or authorization for release of certain protected health information for payment purposes as required by federal, state, or local law, such as information involving communicable or venereal disease, or substance abuse treatment.
   
   
3. 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. If you are not home, we may leave this information on your answering machine or in a message left with the person answering the telephone. You have a right to stop appointment reminders if you will let us know your decision.
   
   
4. Health Related Benefits and Services
   We may use and disclose protected medical information to tell you about health-related benefits or services or recommend possible treatment options or alternatives that may be of interest to you.
   
   
5. Business Associates
   We may disclose your protected health information to business associates that are separate or independent of our office, with whom we contract to provide services on our or their behalf. However, we will only make these disclosures if we have received satisfactory assurance that the associates will properly safeguard information. For example, we may contract with a company to provide monthly billing or to provide collection services for past due accounts.
   
   
6. 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 protected health information to someone who helps pay for your care. You may object to this disclosure by notifying our office. We may also disclose protected health information about you to an entity assisting in a disaster relief effort so that you and your family can be notified about your condition, status, and location.
   
   Special Situations Where Disclosure May or May Not Require Your Consent
   
7. Research
   We may disclose protected medical information about you for research purposes. For example, this may include the study of a new medication.
   
   
8. As Required by Law
   We will disclose protected medical information about you when required to do so by federal, state, or local law.
   
   
9. 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. Any disclosure, however, would only be to someone able to help prevent the threat.
   
   
10. Military and Veterans
    If you are a member of the armed forces, we may release protected health information about as required by military command authorities. We may also release protected medical information about foreign military personnel to the appropriate foreign military authority. We may use and disclose to components of the Department of Veterans Affairs medical information about you to determine whether you are eligible for certain benefits.
    
    
11. Workers Compensation
    We may release protected medical information about you for workers’ compensation or similar programs. Release of such information is controlled by state and/or federal laws. These programs provide benefits for work-related injuries or illness.
    
    
12. Public Health Reporting
    We may disclose protected medical information about you for public health activities to, for example:
    • To prevent or control disease, injury, or disability
    • To report births and deaths
    • To report cancer diagnoses and tumors
    • To report child abuse or neglect
    • To report vulnerable adult abuse
    • To report reactions to medication or problems with products
    • To notify people of recalls of products they may be using
    • To notify a person and/or the Oklahoma State Department of Health that a person may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition
    • To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence, if you agree or when required by law.
    
    
    
13. Health Oversight Activities
    We may disclose protected medical information to a health oversight agency for activities authorized by law. This may 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.
    
    
14. Court Orders
    If you are involved in a lawsuit or a dispute, we may disclose protected medical information about you in response to a court or administrative order. 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.
    
    
15. Law Enforcement
    We may release protected medical 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 in our office
    • In emergency circumstances to report a crime, the location of the crime or victims, to the identity location, location or description of the person who committed the crime
    
    
16. Coroners, Medical Examiners, and Funeral Directors
    We may release protected medical information to a coroner or medical examiner. For example, to identify a deceased person or determine the cause of death. We may also release protected medical information to a funeral director as necessary for them to carry out their duties.
    
    
17. National Security and Intelligence Activities
    We may disclose protected medical information about you to authorized federal officials for intelligence, counter-intelligence, and other national security activities authorized by law.
    
    
18. Protective Services for the President and Others
    We may disclose protected medical information about to authorized federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state or conduct special investigations.
    
    
19. 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 the institution to provide you with health care; (2) to protect your health and safety of the health and the safety of others; or (3) for the safety and security of the correctional institution.

1. Right to Inspect and Copy
   You have the right to inspect and request a copy of your protected medical information including the medical billing records used to make decisions about your care. You also have the right to authorize third parties to obtain your protected medical information.
   
   To inspect, by appointment, and/or request a copy of your protected medical information, you must submit your request in writing. 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 25 cents a page.
   
   We may deny your request to inspect and copy in certain circumstances. If you are denied, you may request that denial be reviewed. Some types of records such as psychotherapy notes may be denied to you and no review is allowed. Other records may be denied for personal safety or potential harm reasons, but you may obtain a review of this denial.
   
   You have the right to revoke in writing an authorization, but prior disclosures will not be affected.
   
   
2. 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 to the Privacy Office that states and supports the reason for the request. We may deny your request for an amendment if it is not in written 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:
   • Was not created by us, unless the person or entity that created the information is n longer available to make the amendment
   • Is not part of the medical information kept by our office
   • Is not part of the information which you would be permitted to inspect and copy; or in our judgment is accurate and complete as it appears
   
   
3. Right to An Account Disclosure
   You have the right to request one free accounting of disclosure we made of protected medical information about you every 12 months. You must submit your request in writing to the Privacy Office. Your request must state a time period which may not be longer than six years and may not include dates before April 1, 2004. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
   
   
4. 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. You have the right to request a limit on the protected medical information we disclose about you to someone who is involved in our care or the payment for your care, like a family member or friend. In certain situations, 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 emergency treatment.
   
   To request restrictions, you must make your request in writing on a form that we will provide you. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, or disclosure or both; and (3) to whom you want the limits to apply.
   
   
5. Right to Request Confidential Communication
   You have the right to request that our office 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 by mail.
   
   To request confidential communication, you must make your request in writing to the Privacy Office in our office. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you with to be contacted.
   
   
6. Right to a Paper Copy of This Notice
   You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact our office.