UROLOGY ASSOCIATES, INC. NOTICE OF PRIVACY PRACTICES
Effective Date: April 14, 2003
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, please contact Heather Gardner at
WHO WILL FOLLOW THIS NOTICE:
This notice describes the practices of the office of Urology Associates and that of:
Any health care professional authorized to enter information into your file or record.
All employees, staff and other personnel.
All business associates with whom we contract to provide services on our behalf.
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 in our practice. Your medical records and billing information are systematically created and retained on a variety of media, which may include computers, paper and films. We need this record to provide you with quality care and to comply with certain legal requirements. Your record is accessible to our medical staff and members of our personnel. Proper safeguards are in place to discourage improper use or access.
This notice will tell you about the ways in which we may use and disclose medical information about you. It also describes your rights and certain obligations we have regarding the use and disclosure of medical information.
We are required by law to:
---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; and
---follow the terms of the notice that is currently in effect.
HOW WE MAY USE AND DISCLOSE YOUR MEDICAL INFORMATION.
The following categories describe different ways that we use and disclose medical information. All of the ways we are permitted to use and disclose information without your authorization will fall within one of these 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, nurses, technicians, medical students, or other personnel who are involved in your care. Different departments of our practice also may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays. We also may disclose medical information about you to people outside the practice who may be involved in your medical care, such as providers of ancillary services (pathology, diagnostic imaging, etc.).
For Payment: We may use and disclose protected health information about you so that the treatment and services you receive under our care 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. 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.
Business Associates: We may disclose your protected health information to Business Associates independent of our practice with which we contract to provide services on our behalf. However, we will only make these disclosures after we have received satisfactory assurance that the Business Associate will properly safeguard your privacy and the confidentiality of your protected health information. For example, we may contract with a company outside of our practice to provide medical transcription services, or to provide collection services for past due accounts.
Appointment Reminders: We may use and disclose your protected health information to contact you as a reminder that you have an appointment for treatment or medical care.
Treatment Alternatives: We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
Health-Related Benefits and Services: We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.
Individuals Involved In Your Care or Payment for Your Care: We may release medical information about you to a spouse or relative who is involved in your medical care, and who is legally authorized to receive that information. We may also give information to someone who helps pay for your care.
As Required By Law: We will disclose protected health information about you when required to do so by federal, state or local law.
To Avert a Serious Threat to Health or Safety: We may use and disclose 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.
Organ and Tissue Donation: If you are an organ donor, we may release medical information to organizations that handle procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.
Military and Veterans: If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.
Workers' Compensation: We may release protected health information about you for workers' compensation or similar programs as authorized by state law. These programs provide benefits for work-related injuries or illness.
Public Health Risks: We may disclose medical information about you for public health activities. These activities generally include the following:
---to prevent or control disease, injury or disability;
---to report births and deaths;
---to report child abuse or neglect;
---to report vulnerable adult abuse;
---to report reactions to medications or problems with products;
---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;
---to notify the appropriate government authority if we believe a patient has been the
victim of domestic violence. We will only make this disclosure if you agree or when
required or authorized by law.
Health Oversight Activities: We may disclose protected health information to a health oversight agency for activities necessary for the government to monitor the health care system, government programs, and compliance with applicable laws. These oversight activities include, for example, audits, investigations, inspections and medical device reporting and licensure.
Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose 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.
Law Enforcement: We may release 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 involving 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.
Coroners, Medical Examiners, and Funeral Directors: We may release protected health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about patients to funeral directors as necessary to carry out their duties.
National Security and Intelligence Activities: We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
Protective Services for the President and Others: We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.
Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be necessary (1) for this practice to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION
You have the following rights regarding protected health information we maintain about you:
1. Right to Inspect and Copy: You have the right to inspect and request a copy of your protected health information, except as prohibited by law.
To inspect and/or request a copy of your protected health information, you must
submit your request to our office in writing. If you request a copy of the information, we may charge a fee of $.25 per page to offset the costs associated with the request.
2. Right to Amend: If you feel that protected health 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 that states the reason for the request.
We may deny your request for an amendment if it is not in writing 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 no longer available to make the amendment;
---is not part of the medical information kept by our practice;
---is not part of the information which you would be permitted to inspect and copy; or
---is accurate and complete.
3. Right to an Accounting of Disclosures: You have the right to request an "accounting of disclosures." This is a list of the disclosures we have made of your medical information. You have the right to request one free accounting of this list every 12 months. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, paper, disk or e-mail). For more than one list in a 12-month period, we may charge you for the costs of providing the additional list(s). 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 health information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. 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.
To request restrictions, you must make your request in writing. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure, or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.
5. Right to Request Confidential Communications: You have the right to request that we 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 communications, you must make your request in writing. We will not ask you the reason for the request. We will accommodate all reasonable requests. Your request must specify how or where you wish 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. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.
To obtain a paper copy of this notice, contact:
HIPAA Privacy Officer
Urology Associates, Inc.
11000 Hefner Pointe Drive
Oklahoma City, OK 73120-5039
CHANGES TO THIS NOTICE
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in our office. The notice will contain on the first page, in the top right-hand corner, the effective date. In addition, each time you are in our office for treatment or health care services, we will make available to you a copy of the current notice in effect.
AUTHORIZATION FOR OTHER USES OF PROTECTED HEALTH 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 authorization. If you provide us authorization to use or disclose protected health information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose protected health 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 authorization, and that we are required to retain our records of the care that we provided to you.
If you believe your privacy rights have been violated, you may file a written complaint with our office or with the Secretary of the Department of Health and Human Services. To file a complaint with our office, contact:
Urology Associates, Inc.
Attn: Heather Gardner
11000 Hefner Pointe Drive
Oklahoma City, OK 73120-5039
To file a written complaint with the Secretary of the Department of Health and Human Services, contact:
The U.S. Dept. of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201
The complain to the Secretary must be filed within 180 days of when the complainant knew or should have known that the act or omission complained of occurred. The complaint must be in writing, either on paper or electronically, name the entity that is the subject of the complaint and describe the acts or omissions believed to be in violation of the standards.
You will not be penalized for filing a complaint.