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PATIENT INFORMATION PRIVACY NOTICE
FOR
ADULT GASTROENTEROLOGY ASSOCIATES, INC.
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
This notice describes the health and medical information policies and procedures of Adult Gastroenterology Associates,
Inc. It applies to all staff, employees, independent contractors, and business associates of this practice.
OUR PLEDGE REGARDING YOUR MEDICAL INFORMATION
The physicians and staff of Adult Gastroenterology Associates 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 medical information about you
HOW WE MAY USE AND DISCLOSE YOUR MEDICAL INFORMATION
For Treatment: We may use medical information about you to provide you with medical treatment or services.
We may disclose medical information about you to doctors, nurses, technicians, medical students, 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 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 family members, or others we use to provide services that are part of your care. When you arrive
in our office for an appointment with your physician you will announce your name to the receptionist, when it is
time for you to enter the clinical area for the appointment your name will be called in the waiting room.
For Payment: We may use and disclose medical information about you so that the treatment and 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 insurance company information about treatment you received so your insurance company will
pay us or reimburse you. We may also tell your insurance company about a treatment you are going to receive to
obtain prior approval or to determine whether your plan will cover the treatment.
Appointment Reminders: We may use and disclose medical information to contact you as a reminder that you
have an appointment for treatment or medical care.
Individuals Involved in Your Care or Payment for Your Care: We may release medical information about you
to a family member who is involved in your medical care. We may also give information to someone who helps pay
for your care. In addition, we may disclose 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 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 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 Donation: If you are an organ donor, we may release 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 medical information about
you as required by military command authorities.
We may also release medical information about foreign military authority.
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. Release of such information
is controlled by state and federal law.
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
- To report births and deaths
- 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
National Security: We may release protected medical information about you to authorized federal officials for
intelligence, counterintelligence, and other national security activities authorized by law.
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
- 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 medical information to a medical examiner. This
may be necessary, for example, to identify a deceased person or determine cause of death.
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU
You have the following rights regarding 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. Usually, this includes medical and billing records, but does not include psychotherapy
notes.
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 tot 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 and submitted to your physician at Adult Gastroenterology
Associates. In addition, you must provide a reason that supports your 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.
Right to an Accounting of Disclosures: You have the right to request an "accounting of disclosures".
This is a list of the disclosures we made of medical information about you.
To request this accounting of disclosures, you must submit your request in writing to the Practice Administrator.
Your request must state a time period which may not be longer than six years and may not include dates prior to
April 14, 2003.
The first list you request will be free. For additional requests for lists we may charge you for the costs related
to providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request
before costs are incurred.
RIGHT TO REQUEST RESTRICTIONS
You have the right to request a restriction or limitation on the medical 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.
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. You must tell us (1) what information you want
limited; (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.
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
your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be
contacted.
RIGHT TO A COPY OF THIS NOTICE
You have the right to a copy of this notice. You may ask us to give you a copy of this notice at any time.
You may also obtain a copy of this notice at our website. www.adultgastro.com
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. This notice will contain on the first page, in the top right-hand
corner, the effective date.
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 may contact Mark Nightengale,
M.D. our Privacy Officer or Linda Jones the Administrator. Adult Gastroenterology Associates, Inc., 6465 South
Yale, Suite 715, Tulsa, Ok. 74136. All complaints must be submitted in writing.
You will not be penalized for filing a complaint.
OTHER USES OF MEDICAL INFORMATION
Other uses and disclosures of 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 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 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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