Patient Privacy
Notice
Effective April 1,
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 CAREFUL
If you have any questions about this notice, please contact the receptionist.
WHO WILL FOLLOW
THIS NOTICE:
- Any health care
professional authorized to enter information into your file or record.
- All physicians,
technologists, nurses, receptionists, transcriptionists, patient transporters,
filing data entry and billing personnel.
- Medical Plaza
Imaging, Comprehensive Breast Center of Oklahoma, Integris Health
and it's entities, Deaconess Hospital and it's entities, Canadian
Valley Regional Hospital, Northwest Surgical Hospital, Oliver Cvitanic,
MD and Gregory Henzie, MD follow the terms of this notice.
In addition, these
entities, sites and locations may share medical information with each
other for treatment, payment or hospital operations purposes described
in this notice.
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.
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.
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 protected
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 may use and
disclose protected medical information. For each category of uses or
disclosures we will explain what we mean. 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 Diagnostic Testing: We may use protected
medical information about you to provide you with diagnostic services.
We may disclose protected medical information about you to doctors,
technologists, nurses, medical students, pharmacists or other personnel
who are involved in taking care of you. Different departments of our
practice also may share medical information about you in order to coordinate
the different things you need, such as pre-procedural preps, x-rays,
scans and ultrasounds. We also may disclose protected medical information
about you to people outside the practice who may be involved in your
medical care, such as family members or others used to provide services
that are part of your care.
For Payment: We may use and disclose protected
medical information about you so that the 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 the services you received so your health plan will
pay us or reimburse you. We may use and disclose your information to
obtain payment from third parties that may be responsible for such costs,
such as family members. And we may use your information to bill you
directly for services and items.
Appointment Reminders: We may use and disclose
protected medical information to contact you as a reminder that you
have an appointment for diagnostic services.
Diagnostic Alternatives: We may use and disclose
protected medical information to tell you about or recommend possible
diagnostic options or alternatives that may be of interest to you.
Health-Related Benefits and Services 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 information to someone who helps pay for your care. We
may also tell your family or friends your condition. In addition, we
may disclose protected medical information about you to an entity assisting
in a disaster relief effort so that your family can be notified about
your condition, status and location.
As Required By Law: We will disclose protected
medical 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 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.
SPECIAL SITUATIONS:
Organ and Tissue Donations: If you are an organ
donor, we may release protected medical information to organizations
that handle organ 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 protected medical information about
you as required by military command authorities. We may also release
protected medical information to foreign military authority, if you
are in their service.
Workers Compensation: We may release protected
medical information about you for workers compensation or similar programs.
These programs provide benefits for work-related injuries or illness.
State and/or federal law control release of such information.
Public Health Risks: We may disclose protected
medical information about you for public health activities. These activities
generally include the following:
- to prevent or
control disease, injury or disability;
- to report a known
or suspected crime;
- 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 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.
Lawsuits and Disputes: If you are involved in
a lawsuit or a dispute, 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.
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 persons 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.
Medical
Examiners and Funeral Directors: We may release protected medical
information to a medical examiner. This may be necessary, for example,
to identify a deceased person or determine the cause of death. We may
also release protected medical information about patient to funeral directors
as necessary to carry out their duties.
National Security and Intelligence Activities:
We may release protected medical information about you to authorized federal
officials for intelligence, counter intelligence, and other national security
activities authorized by law.
Protective Services for the President and Others:
We may disclose protected 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 protected 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 MEDICAL INFORMATION ABOUT YOU:
You have the following rights regarding protected medical information
we maintain about you:
Right to Inspect and Copy: You have the right
to inspect and copy medical information that may be used to make decisions
about your care. This includes medical and billing records.
To inspect and/or copy your medical information you must submit your
request to:
Radiology Associates,
Inc.
Film Room
3435 N.W. 56, Bld A, Suite 200
Oklahoma City, OK 73112
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 requests. (By statute in Oklahoma
we may charge you $0.25 per page for copies, plus our postage costs. If
your record contains any item that requires a photographic process to
copy x-rays or photograph, we may charge you up to $5.00 per image.)
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 office. To request an amendment, your
request must be made in writing and submitted to:
Radiology Associates,
Inc.
Safety Officer
3330 N.W. 56, Suite 206
Oklahoma City, OK 73112
In addition, you must
provide a reason that supports your amendment 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
- in our judgment
is accurate and complete as it appears or as it was at the time it
was originally captured and recorded.
Right
to an Accounting of Disclosures: You have the right to request an
"accounting of disclosures." This is a list of disclosures we have made
of your medical information.
To request this list or accounting of disclosures, you must submit your
request in writing to:
Radiology Associates,
Inc.
Safety Officer
3330 N.W. 56th Street, Suite 206
Oklahoma City, OK 73112
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, on paper or electronically, i.e. on disk).
The first list you request within each 12-month period will be free. 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.
Right to Request Restrictions: You have the right
to request restriction or limitation on the protected medical information
we use or disclose about you for treatment, payment or health care operations.
However, we must receive your restrictions in writing before we have made
such disclosures. Also, if you restrict our right to use your protected
medical information for treatment, payment or health operations, we reserve
the right to immediately withdraw our services from you and terminate
the physician-patient relationship.
You also have the right to request a limit on the protected medical information
we disclose about you to someone who is involved in your care or the payment
for your care, such as a family member or friend. For example, you could
ask that we not use or disclose information about a surgery to your family.
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 to:
Radiology Associates,
Inc.
Safety Officer
3330 N.W. 56th Street, Suite 206
Oklahoma City, OK 73112
If you request restrictions,
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.
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 protected 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 offer you a copy of the current
notice in effect.
COMPLAINTS:
If you believe your privacy rights have been violated, you may file
a complaint with our office or with the Secretary of the Department
of Health and Human Services. To file a complaint with our office, you
must make your request in writing to
Radiology Associates,
Inc.
Safety Officer
3330 N.W. 56th Street, Suite 206
Oklahoma City, OK 73112
All complaints must
be in writing. You will not be penalized for filing a complaint
OTHER USES OF
MEDICAL INFORMATION:
Other uses and disclosures of protected medical 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 to retain our records of the care that we provided
to you
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