NOTICE OF PRIVACY PRACTICES
Effective Date: December 1, 2018
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.
The Spine and Pain Center is committed to protecting your medical information. This Notice describes your rights and our legal
duties regarding your protected health information. We create and maintain, on a variety of media, including paper, computers
and films, a record of the care and services you receive. This information is available to all Office Practice employees, and
physicians, who need this information to provide treatment to you, to obtain payment for services rendered to you or to
support health care operations necessary for the operational aspects of your care. We are required by law to:
Have proper safeguards in place to discourage improper use or access.
Protect the privacy and confidentiality of your personal and protected health information and records.
Describe your rights and our legal duties regarding your protected health information.
WHAT DO THESE WORDS MEAN?
Protected Health Information (PHI)
Your personal and protected health information created and used by us to provide care to you and bill for services provided.
The person responsible for the policies and procedures developed to protect your PHI and for investigating your complaints on
how your PHI is used or disclosed.
An independent business or individuals who contracts with the Office Practice for services provided to you or the Office
A document signed by you that gives us permission to use or disclose your PHI for purposes other than your treatment,
obtaining payment for your treatment or our health operations.
WHAT WILL YOU DO WITH MY MEDICAL AND BILLING INFORMATION?
The following categories describe how we may use and disclose your protected health information. Not every use or disclosure
in a category will be listed. To ensure compliance with Oklahoma law, we will obtain your consent for the use and disclosure of
your protected health information. INFORMATION USED AND DISCLOSED MAY INCLUDE RECORDS WHICH MAY INDICATE THE
PRESENCE OF A COMMUNICABLE OR VENEREAL DISEASE AND MAY INCLUDE, BUT ARE NOT LIMITED TO, DISEASES SUCH AS
HEPATITIS, SYPHILIS, GONORRHEAH, AND THE HUMAN IMMUNO- DEFICIENCY VIRUS ALSO KNOWN AS ACQUIRED IMMUNE
DEFICIENCY SYNDROME (AIDS). If you do not consent, we cannot provide you treatment except in emergency situations or
when we cannot communicate with you for some other reason.
1. Treatment: We may use your protected health information to provide you with medical treatment or services. We may
disclose your protected health information to doctors, nurses, technicians, medical student, or other Office Practice personnel
who are involved in your care.
o The surgeon treating your broken leg may need to know if you have diabetes because diabetes may slow the healing process.
o The doctor treating you for high blood pressure may ask a nurse to take your blood pressure and report this to the doctor. We
also may disclose your medication information to other medical personnel outside the office practice that will provide medical
treatment or services.
o The treating doctor may send a sample of your blood to be tested at a lab and inform the lab of your condition and a brief
medical history so the lab will know what tests to run.
2. Payment: We may use and disclose your protected health information so that the treatment and services you receive may be
billed to and payment collected from you, your insurance or a third party. This may include certain activities that your health
plan may undertake before it approves or pays for the health services we recommend for you such as: making a determination
of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking
utilization review activities.
o We may need to give your health plan copies of your physician’s chart notes about the treatment you received in the office
for high blood pressure so your health plan will pay us or reimburse you for the treatment.
o We may also tell your health plan about a blood pressure treatment you are going to receive to obtain prior approval or to
determine whether your plan will cover the treatment.
3. Health Care Operations: We may use or disclose your protected health information for Office Practice operations. These uses
and disclosures are needed to run the Office Practice and make sure that all of our patients receive quality care. These activities
include, but are not limited to quality assessment activities, employee review activities, training of medical subtends, licensing,
and conducting or arranging for other business activities.
o We may use your blood pressure measurements to review our treatment and services and evaluate the performance of our
stall in caring for you.
o We may also combine medical information about many office patients to decide what additional services the office should
offer, what services are not needed, and what certain new treatments are effective.
o We may also combine medical information we have with medical information from other offices to compare how we are
doing and see where we can make improvements in the care and services we offer.
4. Business Associates: We may disclose your protected health information to Business Associates independent of the Office
Practice and with whom we contract to provide services on our behalf. We will only make these disclosures after receiving
satisfactory assurance that the Business Associate will properly safeguard your privacy and the confidentiality of your protected
o We may contract with a company outside the Office Practice to provide medical transcription services for the Office Practice
or to provide collection services for past due accounts.
5. 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. This may be done through an automated system or by one of our staff
members. If you are not at home or unable to answer the telephone, we may leave this information on your answering
machine or voicemail or in a message left with the person answering the telephone.
6. Health Related Benefits and Services: We may use and disclose your protected health information to provide you with
information about health-related benefits or services to recommend possible treatment options or alternatives that may be of
interest to you. You may contact the designated Privacy Officer to request that these materials not be sent to you.
7. Marketing: We may disclose certain protected health information to a third party to provide marketing materials and
information to you. The Office Practice must obtain consent if we are going to sell your protected health information to a third
party, unless it is for a nominal fee or disclosure is made during face to face communication.
8. Individuals Involved in Your Care or Payment for Your Care: We may release protected health information 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. We may disclose protected health information about you to an entity assisting in a disaster relief efforts so that
your family can be notified about your condition, status and location.
9. Research: Under certain circumstances, we may use and disclose your protected health information for research purposes
or, to determine whether you might benefit from, or be willing to be involved in certain research.
o A research project may involve comparing health and recovery of all patients with high blood pressure who received one
blood pressure medication to those who received another type of blood pressure medication to determine which type is most
o We may disclose your protected health information to people preparing to conduct a research project so long as the
protected health information they review does not leave the office.
Most research only uses medical information without using your name, address or other information that reveals who you are.
We will almost always ask for your specific permission if the researcher will have access to your name, address or other
information that reveals who you are or if your medical information will leave the office.
CAN YOU EVER USE OR DISCLOSE MY PROTECTED HEALTH INFORMATION WITHOUT MY CONSENT?
Yes. The following categories describe ways we may use or disclose your protected health information without your
authorization or opportunity to agree or object. Not every use or disclosure in a category will be listed.
1. Required by Law: We will disclose your protected health information when required to do so by federal, state, or local law.
o Oklahoma law requires us to report all communicable or venereal diseases which are identified or diagnosed in our office to
the Oklahoma State Department of Health.
2. To Avert a Serious Threat to Health or Safety: We may use and disclose your protected health information when necessary
to prevent a serious threat to your health and safety or the health and safety of the public or another person. This disclosure
would only be made to someone able to prevent the threat.
3. Public Health Reporting: We may disclose your protected health information for public health activities and purposes to a
public health authority that is permitted by law to collect or receive the information.
o Prevention or control of disease, injury, or disability.
o Reporting of cancer diagnoses and tumors.
o Reporting of reactions to medications or problems with products.
o Notification of people using products that are recalled.
o Notification of the Oklahoma State Department of Health about people who may have been exposed to a disease or are at
risk for contracting or spreading a disease or condition such as HIV, Syphilis, or other sexually transmitted diseases. o Reporting
of abuse, neglect, or violence as required by law.
o Reporting births and deaths.
4. Communicable Diseases: We may disclose your protected health information to notify of the Oklahoma State Department of
Health about people who may have been exposed to a disease or are at risk for contracting or spreading a disease or condition
such as HIV, Syphilis, or other sexually transmitted diseases. We may also disclose your protected health information, if
authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of
contracting or spreading the disease or condition.
5. Health Oversite Agencies: We may disclose protected health information to a health oversight agency for activities
necessary for the government to monitor the health care system, government regulatory and benefit programs, and
compliance with applicable laws. These oversight activities include, audits, investigations, inspections, medical device reporting
6. Organ and Tissue Donation: If you are organ donor, we may release your protected health information to organizations that
handle organ procurement for organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate
organ or tissue donation and transplantation.
7. Workers’ Compensation: We may release your protected health information for workers’ compensation or similar programs
as authorized by State laws. The programs provide benefits for work related injuries or illness.
8. Lawsuits and Disputes: If you are involved in lawsuit or dispute, we may disclose your protected health information in
response to a court or administrative order. We may also disclose your protected health information 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.
9. Law Enforcement: We may release protected health information, so long as applicable legal requirements are met, for law
enforcement purposes. These law enforcement purposes include:
o Legal processes and otherwise required by law
o Limited information requests for identification and location purposes
o Pertaining to victims of a crime
o Suspicion that death has occurred as a result of criminal conduct
o In the event that a crime occurs on the premises of our practice
o Medical emergency (not on our practice’s premises) and it is likely a crime has occurred*
10. Military Activity: When the appropriate conditions apply, we may use or disclose protected health information of
individuals who are Armed Forces personnel for activities deemed necessary by appropriate military command authorities, for
the purposes of a determination by the Department of Veterans Affairs of your eligibility for benefits, or to foreign military
authority if you are a member of that foreign military service.
11. Coroners, Medical Examiners, and Funeral Directors: We may disclose protected health information to a coroner or
medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform
other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law,
in order to permit the funeral director to carry out their duties, such as to assist the funeral director in completing the death
12. Food and Drug Administration: We may disclose your protected health information to a person or company required by the
Food and Drug Administration for the purpose of quality, safety, or effectiveness of FDA-regulated products or activities
including, to report adverse event, product defects or problems, biologic product deviations, to track products, to enable
product recalls, to make repairs or replacements, or to conduct post marketing surveillance, as required.
13. National Security and Intelligence Agencies: We may disclose your protected health information to authorized federal
officials for intelligence, counterintelligence and other national security activities authorized by law. We may also disclose your
protected health information to authorized federal officials so they may provide protection to the President, other authorized
persons or foreign heads of state or to conduct special investigations.
14. Inmates: If you are an inmate of the correctional institution or in the custody of a law enforcement official, we may disclose
your protected health information to the correctional facility or law enforcement official. This may be necessary for the
correctional institution to provide you with health care or to protect the health and safety of yourself, others or the
ARE THERE ANY CASE THAT REQUIRE MY WRITTEN AUTHORIZATION FOR DISCLOSURE OR USE OF MY PROTECTED HEALTH
Other uses and disclosures of your protected health information will be made only with your written authorization, unless
otherwise permitted or required by law as described below. You may revoke this authorization in writing at any time. If you
revoke your authorization, we will no longer use or disclose your protected information for the reasons covered by your written
authorization. Please understand that we are unable to take back any disclosures already made with your authorization. Your
prior written authorization is required for:
o Most uses and disclosures of psychotherapy notes. o Uses and disclosures of PHI for marketing purposes. o Disclosures of PHI
that constitutes a “sale”
Others Involved in Your Health Care or Payment for Your Care: We may use or disclose your protected health information in the
following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health
information. Unless you object, we may disclose to a member of your family, a friend, or any other person you identify, your
protected health information that directly relates to that person’s involvement in your health care. If you are not present or
able to agree or object to the use or disclosure of the protected health information, then we may, using professional
judgement, determine whether the disclosure is in your best interest. We may use or disclose protected health information to
notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of
your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized
public or private entity to assist in disaster relief effort and to coordinate uses and disclosures to family or other individuals
involved in your care.
WHAT ARE MY RIGHTS REGARDING MY PROTECTED HEALTH INFORMATION?
You have the following rights regarding the protected health information that we maintain about you. You are required to
submit a written request to exercise any of these rights for records we create and maintain.
1. Right to Inspect and Copy Health Information: You have the right to inspect and request a paper or electronic copy of your
protected health information, except as prohibited by law, for so long as we maintain the protected health information. You
may obtain your medical record that contains medical and billing records and any other records that your physician and the
Office Practice uses for making decisions about you. If you request a paper copy of your protected health information, we may
charge 25 cents per page, as permitted by law. Under federal law, however, you may not inspect or copy the following records:
psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or
proceeding; and laboratory results that are subject to law that prohibits access to protected health information. Depending on
the circumstance, a decision to deny access may be reviewable.
2. Right to Request a Change in Protected Health Information: If you feel that the protected health information created by us
is incomplete or incorrect, you may request an amendment for as long as we maintain the information. You must provide a
reason that supports your amendment request. If your request is not in writing or does not include a reason to support your
request for amendment, we may deny your request for amendment. We may also deny you request for amendment if you ask
us to amend information that:
We did not create, unless the person or entity that created the information is no longer available to make the amendment.
Is not part of the protected health information maintained by the Office Practice.
Is not part of the information that you would be permitted to inspect or copy.
Is accurate and complete.
If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a
rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Officer if you have
questions about amending your medical record.
3. Right to Request Confidential Communication: You have the right to request that we communicate with you about your
protected health information in a certain way or certain locations. For example, you request that we only contact you via mail
or at your work phone number. We will not ask you the reason for the request. We will accommodate all reasonable requests.
You request must specify how or where you wish to be contacted. Please make this request in writing to our Privacy Officer.
4. Right to Request a Restriction of Protected Health Information: 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 or limit the protected health information we disclose about you to a family member or friend who may be
involved in your care or for notification purposes as described in this Notice of Privacy Practices. We are not required to agree
with your request. If we do not agree, we will comply with your request unless the information is needed to provide you with
emergency treatment or the use or disclosure is required by law. Your written request must include:
What information you want restricted.
The type of restriction you want.
To whom you want the restriction to apply.
5. Right to Restrict Disclosure of Certain Protected Health Information to Health Plans: If you pay out-of-pocket for your
health care item or service in full, you have the right to request that we not share the protected information about that item or
service with your health plan. We are required to comply with this request, unless mandated to do otherwise by law.
6. Right to Notification of a Breach of Protected Health Information: We are required by law to tell you if there is breach of
your protected health information. A breach is defined as the acquisition, access, use, or disclosure of protected health
information in a manner that compromises the privacy or security of the protected health information.
7. Right to an Accounting of Disclosures: You have the right to request an accounting of disclosures of your protected health
information that we have made. This right applies to disclosures for purposes other than treatment, payment or health care
operations as described in this Notice of Privacy Practices. Your request must be in writing and must state the time period for
the requested information. The Office Practice will not provide information for a time period greater than six (6) years from the
date of your request. You have the right to request one free accounting of disclosures every 12 months. For additional
accountings, we may charge you for the costs of providing the accounting. We will notify you of the cost involved and you may
choose to withdraw or modify your request at that time before any charges are incurred.
8. Right to Opt Out of Any Fundraising Communications: You have the right to choose not to be included in any fundraising
efforts or communications from the Office Practice.
9. 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, contact our Privacy Officer.
CAN YOU CHANGE THIS NOTICE?
We reserve the right to change this notice at any time. We reserve the right to make the revised or changed notice effective for
your protected health information we already have about you as well as for any protected health information we receive or
create in the future. Each notice will have an effective date. Copies of the current notice will be posted and made available
upon request and in our office.
WHAT IF YOU WANT TO USE OR DISCLOSE MY PROTECTED HEALTH INFORMATION FOR A PURPOSE NOT DESCRIBED IN THIS
Other uses and disclosures not covered by this notice or the laws that apply to us will only be made with your written
authorization. In other words, the consent you have already provided us will not be enough to use or disclose your protected
health information for any purpose not described in this notice. If you provide us authorization to use or disclose your
protected health information, you may revoke that authorization, we will no longer use or disclose your protected health
information for the reasons covered by your authorization. You understand that we are unable to take back any uses or
disclosures we have already made with your authorization.
WHAT IF I HAVE A QUESTION OR NEED TO REPORT A PROBLEM?
If you have any question about this Notice, or any concerns about the privacy of your protected health information, please
contact the practice’s Privacy Officer. We hope you will tell us if you have a concern so we can try to address the issue, but you
also have the right to file a complaint with the Office for Civil Right (OCR). If you decide to file a complaint with the practice or
the OCR, you will not be penalized.