Health Insurance Portability and Accountability Act (HIPAA) Notice of Privacy Practices
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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.

Elite Pain & Health, PC uses and discloses health information about you for treatment, to obtain payment for treatment, for administrative purposes, and to evaluate the quality of care that you receive.

This notice describes our privacy practices. You can request a copy of this notice at any time. For more information about this notice or our privacy practices and policies, please contact our privacy officer. The contact information is listed below, under “Questions and Contact Person for Requests”.

Treatment: We are permitted to use and disclose your medical information to those involved in your treatment. For example, when we provide treatment, we may request that your primary care physician share your medical information with us. Also, we may provide your primary care physician information about your particular condition so that he or she can appropriately treat you for other medical conditions, if any.

Payment: We are permitted to use and disclose your medical information to bill and collect payment for the services provided to you. For example, we may complete a claim form to obtain payment from your insurer or HMO. The form will contain medical information, such as a description of the medical service provided to you, that your insurer or HMO needs to approve payment.

Health Care Operations: We are permitted to use or disclose your medical information for the purposes of health care operations, which are activities that support Elite Pain & Health, PC and help provide the delivery of quality care to you. For example, we may engage the services of a professional to aid Elite Pain & Health, PC in its compliance programs. This person may review billing and medical files to ensure we maintain our compliance with regulations and applicable state and federal law.

Disclosures That Can Be Made Without Your Authorization: There are rare situations in which we are permitted by law to disclose or use your medical information without written authorization or opportunity to object, such as to protect the public. In most situations we will ask for your written authorization before using or disclosing any identifiable health information about you. If you choose to sign an authorization to disclose information, you can later revoke that authorization in writing. However, any revocation will not apply to disclosures or uses already made or taken in reliance on the original authorization.

Public Health, Abuse or Neglect, and Health Oversight: We may disclose your medical information for public health activities. Public health activities are mandated by federal, state, or local governments for the collection by a public health authority of information about disease and/or vital statistics (such as births and deaths). We may disclose medical information, if authorized and/or required by law, to a person who may have been potentially exposed to a disease or may be at risk for contracting or spreading a disease or condition. We may disclose your medical information to report reactions to medications, problems with products, or to notify people of recalls of products they may be using.

We may also disclose medical information to a public agency authorized to receive reports of abuse or neglect. Oklahoma law requires physicians to report child abuse or neglect. Regulations also permit the disclosure of information to report abuse or neglect of elders or the disabled. We may disclose your medical information to a health oversight agency for those activities authorized and/or required by law. Examples of these activities are audits, investigations, licensure applications and inspections which are all government activities undertaken to monitor the health care delivery system and compliance with other laws, such as civil rights laws.

Legal Proceedings and Law Enforcement: We may disclose your medical information in the course of judicial or administrative proceedings in response to an order of the court (or the administrative decision-maker) or other appropriate legal process. Certain requirements must be met before the information is disclosed.

If asked by a law enforcement official, we may disclose your medical information under limited circumstances provided that the information:

Is released pursuant to legal process, such as a warrant or subpoena;

Pertains to a victim of crime and your are incapacitated;

Pertains to a person who has died under circumstances that may be related to criminal conduct;

Is about a victim of crime and we are unable to obtain the person’s agreement;

Is released because of a crime that has occurred on these premises; or

Is released to locate a fugitive, missing person, or suspect.

We may also release information if we believe the disclosure is necessary to prevent or lessen an imminent threat to the health or safety of a person.

Workers’ Compensation: We may disclose your medical information as required by Oklahoma workers’ compensation law.

Inmates: If you are an inmate or under the custody of law enforcement, we may release your medical information to the correctional institution or law enforcement official. This release is permitted to allow the institution to provide you with medical care, to protect your health or the health and safety of others, or for the safety and security of the institution.

Military, National Security and Intelligence Activities, Protection of the President: We may disclose your medical information for specialized governmental functions such as separation or discharge from military service, requests as necessary by appropriate military command officers (if you are in the military), authorized national security and intelligence activities, as well as authorized activities for the provision of protective services for the President of the United States, other authorized government officials, or foreign heads of state.

Research, Organ Donation, Coroners, Medical Examiners, and Funeral Directors: When a research project and its privacy protections have been approved by an Institutional Review Board or privacy board, we may release medical information to researchers for research purposes. We may release medical information to organ procurement organizations for the purpose of facilitating organ, eye, or tissue donation if you are a donor. Also, we may release your medical information to a coroner or medical examiner to identify a deceased or a cause of death. Further, we may release your medical information to a funeral director where such a disclosure is necessary for the director to carry out his or her duties.

Required by Law: We may release your medical information where the disclosure is required by law.

Your Rights Under Federal Privacy Regulations: The United States Department of Health and Human Services created regulations intended to protect patient privacy as required by the Health Insurance Portability and Accountability Act (H1PAA). Those regulations create several privileges that patients may exercise. We will not retaliate against a patient that exercises their HIPAA rights.

Requested Restrictions: You may request that we restrict or limit how your protected health information is used or disclosed for treatment, payment, or healthcare operations. We do NOT have to agree to this restriction except as stated below, but if we do agree, we will comply with your request except under emergency circumstances.

To request a restriction, submit the following in writing: (a) The information to be restricted, (b) what kind of restriction you are requesting (I.e. on the use of information, disclosure of information or both), and (c) to whom the limits apply. Please send the request to the address and person listed below. You may also request that we limit disclosure to family members, other relatives, or close personal friends that may or may not be involved in your care. We must agree to restrict disclosures of health information to a health plan for payment or health care operations purposes if you paid for an item or services out- of-pocket.

Receiving Confidential Communications by Alternative Means: You may request that we send communications of protected health information by alternative means or to an alternative location. This request must be made in writing to the person listed below. We are required to accommodate only reasonable requests. Please specify in your correspondence exactly how you want us to communicate with you and, if you are directing us to send information to a particular place, the contact/address information.

Inspection and Copies of Protected Health information: You may inspect and/or copy health Information that is within the designated record set, which is information that is used to make decisions about your care. Requests for copies must be made in writing and we ask that requests for inspection of your health information also be made in writing. Please send your request to the person listed below. We can refuse to provide some of the information you ask to inspect or ask to be copied if the information:

Includes psychotherapy notes.

Includes the identity of a person who provided information if it was obtained under a promise of confidentiality.

Is subject to the Clinical Laboratory Improvements Amendments of 1988.

Has been compiled in anticipation of litigation.

We can refuse to provide access to or copies of some information for other reasons, if, in our professional judgment, we determine that the access requested is likely to endanger your life or safety or that of another person, or that it is likely to cause substantial harm to another person referenced within the information. You have the right to request a review of this decision.

To inspect and copy your medical information, you must submit a written request to the Privacy Officer whose contact information is listed below. If you request a copy of your information, we may charge you a reasonable fee consistent with any relevant state law for the costs of copying, mailing or other costs incurred by us in complying with your request.

Amendment of Medical Information: You may request an amendment of your medical information in the designated record set. Any such request must be made in writing to the person listed below. We will respond within 60 days of your request. We may refuse to allow an amendment if the information;

Wasn’t created by Elite Pain & Health, PC or the physicians of Elite Pain & Health, PC.

Is not part of the Designated Record Set.

Is not available for inspection because of an appropriate denial.

If the Information is accurate and complete.

Even if we refuse to allow an amendment you are permitted to include a patient statement about the information at issue in your medical record. If we refuse to allow an amendment we will inform you in writing. If we approve the amendment, we will inform you in writing.

Accounting of Certain Disclosures: The HIPAA privacy regulations permit you to request, and us to provide, an accounting of disclosures that are other than for treatment, payment, health care operations, or made via an authorization signed by you or your representative. Please submit any request for an accounting to the person listed below. Your first accounting of disclosures (within a 12 month period) will be free. For additional requests within that period we are permitted to charge for the cost of providing the list. If there is a charge we will notify you and you may choose to withdraw or modify your request before any costs are incurred.

Notification of Breach: You have the right to be notified in writing if there is a breach involving your protected health information.

Appointment Reminders, Treatment Alternatives, and Other Health-Related Benefits: We may contact you by telephone, mail, or both to provide appointment reminders, information about treatment alternatives, or other health-related benefits and services that may be of interest to you.

Copy of Notice: You have the right to obtain a paper copy of this notice even if you have agreed to receive it electronically.

Complaints: If you are concerned that your privacy rights have been violated, you may contact the person listed below. You may also send a written complaint to the United States Department of Health and Human Services. We will not retaliate against you for filing a complaint with the government or us. The contact information for the United States Department of Health and Human Services is:

U.S. Department of Health and Human Services HIPAA Complaint

7500 Security Blvd., C5-24-04 Baltimore, MD 21244

Our Promise to You: We are required by law and regulation to protect the privacy of your medical information, to provide you with this notice of our privacy practices with respect to protected health information, and to abide by the terms of the notice of privacy practices in effect.

Questions and Contact Person for Requests: If you have any questions or want to make a request pursuant to the rights described above, please contact:

Elite Pain & Health, PC – Privacy Officer

Attn: Sharell Harris

13100 N. Western Ave Oklahoma City, OK 73114

800-781-1220

This notice is effective as of March 1, 2018.

We reserve the right to update our policies and this notice at any time. Updated policies will be made available through the Privacy Officer at the location listed above.

HIPPA-NOTICE-03012018

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