Notice of Privacy Practices
Central States Orthopedics, Inc.
Effective April 1, 2010
This Notice Describes How Medical Information About You May Be Used And Disclosed And How You Can Receive Access To This Information. Please Review It Carefully. The Privacy Of Your Information Is Important To Us.
We are committed to protecting the privacy of your medical information. We are required by law to maintain the confidentiality of information that identifies you and the care you receive. This Notice describes your rights and our legal duties regarding your “Protected Health Information, (PHI).” Protected Health Information means any information that can be used to identify you. In this Notice, we call that protected information “medical information.” If you have any questions about this Notice, please contact the Privacy Officer for Central States Orthopedics Specialists at 918-481-2767.
How This Medical Practice May Use Or Disclose Your Medical Information
- We will use your medical information to treat you. For example, we may disclose your medical information to other doctors, nurses, technicians, medical students, or other members of our staff who are involved in taking care of you or to other care professionals for additional treatment or follow up care such as home health services. We also may disclose your medical information to people outside our medical practice who may be involved in your care, such as family members
- We may use and disclose your medical information to receive payment for our services from you, an insurance company or third party. For example, we may need to give your health plan information about a procedure we perform at our office so your health plan will pay or reimburse you for the procedure. 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 treatment
- For Health Care Operations. We may use and disclose your medical information to operate this medical practice. For example, we may use this information to review and improve the quality of care we provide, or the competence and qualifications of our professional staff. We may also share your medical information with our business associates, such as computer consultant, that perform administrative services for us. We have a written contract with business associates that contains terms requiring them to protect the confidentiality of your medical information
- Appointment Reminders. We use and disclose your medical information to remind you about appointments. If time allows, we will mail a postcard reminder. Otherwise, we may phone your home. If you are not at home, we may leave this information on your answering machine or in a message left with the person answering the phone
- Sign-in Sheet. We may use and disclose your medical information by having you sign in when you arrive at our office. We may also call your name when we are ready to serve you
- Notification and Communication with Family. We may disclose your medical information to notify and assist in notifying a family member, or another person who is involved in your care unless you ask us not to. In the event of disaster, we may disclose information to a relief organization, such as the Red Cross, so that they may coordinate these notification efforts.We may also disclose information to someone who pays for your care. If you are unable to agree or object to these disclosures, our health care professionals will use their best judgment in communicating with your family and others
- With Your Authorization. We may disclose your medical information for purposes not described in this Notice or otherwise permitted by law only with your written authorization. You may revoke an authorization at any time, in writing, but only as to future uses or disclosures, and only where we have not already acted in reliance on your authorization. Revocations should be delivered to our Privacy Officer
- Required by Law. We may use and disclose your medical information when required to do so by law, but only to the extent and under the circumstances provided in that law
- Lawsuits and Disputes. If you are involved in a lawsuit or dispute, we may disclose your medical information in response to a court or administrative order. We may also 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
- Public Health and Safety. Your medical information may be used or disclosed for public health activities such as assisting public health authorities or other legal authorities to prevent or control disease, injury, or disability; to report birth defects or infant eye infections; to report cancer diagnosis and tumors; to report child abuse; or neglect or a child born with alcohol and substance s in its system,; to report reactions to medications or problems with products; to notify you of recalls of products you may be using; to notify the Oklahoma State Department of Health that a person may have been exposed to or at risk for contacting a communicable disease or condition, or to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence, if the victim agrees to our reporting, or if we are required to do so by law. Your medical information may be disclosed to appropriate persons in order to prevent or lessen a serious and imminent threat to you or to the health and safety of a particular person or the general public
- Specialized Government Functions. We may disclose your medical information for military or national security purposes, national intelligence, protection of the President, or to correctional institutions or law enforcement officers that have you in their lawful custody
- If you are a member of the armed forces, we may release protected health information about you as required by military command authorities
- 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, investigation, inspections, medical device reporting and licensure
- Coroners/Funeral Directors. We may disclose your medical information to coroners in connection with their investigations of death or to funeral director to enable them to carry out their lawful duties
- Organ or Tissue Donations. We may disclose your medical information to organizations involved in procuring, banking or transplanting organs, eyes and tissues, as necessary to facilitate organ or tissue donation or transplant
- Workers’ Compensation. Your medical information may be used or disclosed as required by law related to Workers’ Compensation
- Change of Ownership. In the event that this medical practice is sold or merged with another organization, your medical information will become the property of the new owner, who will have access to it, although you will maintain the right to request that copies of your medical information be transferred to another physician or medical practice
- Law Enforcement. Your medical information may be disclosed to law enforcement authorities to identify or locate suspects, fugitives, witnesses, or victims of crime (with your consent in some circumstances) and to report possible deaths caused by criminal activities or to report crimes on the premises
- We may contact you to give you information about products or services related to your treatment, case management, or care condition, or to direct or recommend other treatments or health-related benefits and services that may be of interest to you. We may also encourage you to purchase a product or service when we see you. We will not use or disclose your medical information for marketing purposes without your written authorization
- We may use your health information for research purposes when an institutional review board or privacy board has reviewed the research proposal and established protocols to ensure the privacy of your health information and has approved the research
By Oklahoma law we are required to notify you that your medical information used or disclosed in this Notice of Privacy Practices may include records which may contain information that indicates that you have a communicable or non-communicable disease. You further understand that your medical information may indicate that you have or have been treated for psychological or psychiatric conditions or substance abuse.
Your Medical Information Rights
You have the right
- To receive a paper copy of this Notice of Privacy Practices
- To request restrictions on certain uses and disclosures of your medical information by written request specifying what information you want to limit and what limitations on our use or disclosure of that information you wish to have imposed. We reserve the right to accept or reject your request and will notify you of our decision. If we agree to a restriction, we may disregard it if the information is needed to provide you emergency treatment
- To request that you receive medical information in a specific way or at a specific location. For example, you may ask that we send information to your work address. We will comply with all reasonable requests submitted
- To review and obtain a copy of your medical information, with limited exceptions defined by law. A reasonable fee may be charged for making copies. Under Oklahoma law, a fee of .25¢ per page is allowed. If you request a copy of a film, you will be charged the actual cost of reproduction. We may also charge for postage if the copies are to be mailed. If we deny your request for copies, you will be informed of your rights to appeal our decision. Even if we accept your request, we may not delete any information already in your medical record
- You also have the right to request that we amend your medical information that you believe is incorrect or incomplete. Your request to amend must be in writing and include the reasons you believe the information is inaccurate or incomplete. We are not required to change your medical information and will provide you with information about this practice’s denial and how you can disagree with the denial. Even if we accept your request, we may not delete any information already in your medical record. You also have the right to request that we add to your record a statement up to two hundred and fifty (250) words concerning any statement or item you believe to be incomplete or incorrect
- To receive an accounting of disclosures made of your medical information by this medical practice unless the disclosures were for certain purposes, or pursuant to your written authorization
If you would like to have a more detailed explanation of these rights, or if you would like to exercise one or more of these rights, contact our Privacy Office at the address below.
Changes to this Notice
We reserve the right to change or amend this Notice of Privacy Practices at any time in the future. After an amendment is made, the revised Notice of Privacy Practices will apply to all protected health information that we maintain. A copy of any revised Notice of Privacy Practices will be made available to you at each appointment.
Complaints about this Notice of Privacy Practices or how this medical practice handles your medical information should be directed to the attention of
Central States Orthopedics
6585 S. Yale Ave Suite 200
Tulsa, OK 74136
You may also submit a complaint to the Secretary of the Department of Health and Human Services.
You will not be penalized for filing a complaint.
Central States Orthopedics complies with applicable Federal laws and does not discriminate on the basis of race,
color, national origin, age, disability, or sex. Central States Orthopedics provides free language services to people
whose primary language is not English, such as: qualified interpreters throughout language line service.
If you need this service, you may contact Will Fernando Ribera or anyone at the front office. If you believe that
Central States Orthopedics has failed to provide this service or discriminated in another way on the basis of race,
color, national origin, age, disability, or sex, you can file a grievance with: Will Fernando Ribera at 6585 S Yale
Ave Suite 200. Tulsa, OK 74136 or 918.481.2767. You can file a grievance in person or by mail or phone. If you
need help filling a grievance, Will Fernando Ribera is available to assist you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaints Portal, available at www.ocrportal.hhs.gov, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C 20201 1-800368-1019, 1-800-537-7697. Complaint forms are available atwww.hhs.gov
Central States Orthopedics cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. Central States Orthopedics proporciona servicio linguisticos gratuitos a personas cuya lengua maternal no es el ingles, como los siguientes: interpretes capacitados a traves del servicio de linea linguistica.
Si necesita recibir este servicio, comuniquese con Will Fernando Ribera o con alguien en la oficina del frente. Si considera que Central States Orthopedics no le proporciono este servicio o lo discrimino de otra manera por motivos de origen etnico, color, nacionalidad, edad, discapacidad o sexo, puede presenter un reclamo a la siguiente persona: Will Fernando Ribera a 6585 S Yale Ave Suite 200. Tulsa, OK 74136 or 918.481.2767. Puede presentar su reclamo en persona o por correo postal, fax o correo electronico. Si necesita ayudapara hacerlo, Will Fernando Ribera esta a su disposicion para brindarsela.
Tambien puede presentar un reclamo de derechos civiles ante la Officina de Derechos Civiles. Del Departmento of Health and Human Services de EE.UU. de manera electronica a traves de www.ocrportal.hhs.gov o bien, por correo postal a la siguiente direccion o por telefonos a los numeros que figuran a continuacion: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C 20201 1-800368-1019, 1-800-537-7697. Puede Obtener los formularios de reclamo en el sitio web www.hhs.gov