NOTICE OF PRIVACY PRACTICES

Urologic Specialists of Oklahoma, Inc., A Professional Corporation
Effective Date: September 23, 2013

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.

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 about you that identifies you or for which there is a reasonable basis to believe the information 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 Urologic Specialists of Oklahoma, Inc. at (918) 392-2200.

HOW THIS MEDICAL PRACTICE MAY USE OR DISCLOSE YOUR MEDICAL INFORMATION

1. Treatment. 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 your family members.

2. Payment. We may use and disclose your medical information to receive payment for our services from you, an insurance company or a 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 us 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 the treatment.
3. 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 a computer consulting service, that perform administrative services for us. We have a written contract with each business associate that contains terms requiring them to protect the confidentiality of your medical information.

4. Appointment Reminders. We may 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 home, we may leave this information on your answering machine or in a message left with the per- son answering the phone.

5. 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 out your name when we are ready to see you.

6. Notification and Communication with Family. We may disclose your medical information to notify or 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 a 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 professionals will use their best judgment in communicating with your family and others.

7. 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 your Privacy Officer. We must obtain your authorization if we intend to disclose psychotherapy notes or sell your medical information.

Marketing. We may contact you to give you information about products or services related to your treatment, case management or care coordination, or to direct or recommend other treatments or healthcare-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.

Research. 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.

8. 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.

9. Lawsuits and Disputes. If you are involved in a lawsuit or a 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.

10. 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 prevent or control disease, injury, or disability; to report birth defects or infant eye infections; to report cancer diagnoses and tumors; to report child abuse or neglect or a child born with alcohol or other substances 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 a disease or may be at risk for contracting or spreading a disease or condition such as HIV, Syphilis, or other sexually transmitted diseases; or to notify the appropriate governmental 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. Also, we may disclose proof of a child's immunization to a school where the law requires the school to have such information before admitting the student.

11. 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.

12. Military. If you are a member of the armed forces, we may release protected health information about you as required by military command authorities.

13. 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, investigations, inspections, medical device reporting and licensure.

14. Coroners/Funeral Directors. We may disclose your medical information to coroners in connection with their investigations of death or to funeral directors to enable them to carry out their lawful duties. USO-0025

15. Organ or Tissue Donation. We may disclose your medical information to organizations involved in procuring, banking or transplanting organs, eyes and tissues, as necessary to facilitate organ or eyes donation or transplantation.
16. Workers' Compensation. Your medical information may be used or disclosed as required by law related to workers' compensation.

17. 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.

18. Law Enforcement. Your medical information may be disclosed to law enforcement authorities to identify or locate suspects, fugitives or 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.
19. Disclosure of Physician Ownership. The following physicians of Urologic Specialists of Oklahoma, Inc., A Professional Corporation have an ownership interest in the Oklahoma Surgical Hospital, a Tulsa specialty hospital:

W. Jason Cook, MD
W. Todd Brookover, MD
Robert R. Bruce, MD
Shaun G.S. Grewal, MD
Curtis R. Powell, MD
Charles R. Pritchard, MD
J. Steve Miller, MD
Oren F. Miller, MD
Sean M. Doyle, MD
Jeremy C. Carrico, MD
Stephen D. Confer, MD
Todd Brookover, MD
James B. McGeady, MD
Marc S. Milsten, MD
Sunshine Murray, MD
Scott E. Litwiller, MD
Michael N. Wilkin, MD
Kevin J. Gancarczyk, MD
Cole B. Davis, MD
James O. L’Esperance, MD

Physician Ownership Self-Disclosure. The Patient Protection and Affordable Care Act (PPACA) mandates Disclosure Requirements when your physician refers you for Certain Imaging Services, such as CT/PET scans and MRIs. When we refer you to our office for MRI, CT, or PET services we are now required to inform you in writing at the time of the referral that you may obtain the same service from another supplier outside the USO group practice. We must also provide you with a written list of suppliers who furnish such services within a 25-mile radius of our office; we do not have any ownership interest in these centers. We do provide CT scans in our office.

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.
  • If you pay out of your pocket in full for healthcare items or services, you have the right to request that we refrain from providing information about that item or service to your health plan, and we must comply with your request. USO-0025
  • 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 re- quests submitted.
  • To review and obtain a copy of your medical information, with limited exceptions defined by law. You must make your request in writing. You may request the information in an electronic format, and you may direct us to transmit the information to someone that you clearly identify and designate. A reasonable fee may be charged for providing paper or electronic copies. Under Oklahoma law, a fee of $1.00 for the first page and 50 cents for each page thereafter 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. For electronic copies, we may charge you the labor and material costs in complying with your request.
  • 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 re- quest, 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 of 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 purposes of treatment, payment, health care operations, certain government functions, or pursuant to your written authorization.
  • If a breach occurs regarding your medical information, you have the right to be notified. We will notify you in writing of the breach as well as what we have done to correct the error. If we need to, we will take additional steps to further protect your information.

Contact:

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 your Privacy Officer listed on the first page of this Notice of Privacy Practices.

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:

Complaints about this Notice of Privacy Practices or how this medical practice handles your medical information should be directed to the attention of our Privacy Officer, Urologic Specialists of Oklahoma, Inc., 10901 E 48 St S, Tulsa, Oklahoma 74146. There will be no retaliation for filing a complaint. 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.

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