New Patients


Notice of Privacy Practices

Original Effective date: 04-14-03
Revised 12-14-16

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.

Our office is required by law to maintain the privacy of your personal health information. We must:

  • Make sure that medical information that identifies you is kept private (with certain exceptions according to law);
  • Give you this notice of our legal duties and privacy practices with respect to medical information about you; and
  • Follow the terms of this notice.

We reserve the right to change the privacy practices described in this notice, in accordance with the law. Changes to our Privacy Practices would apply to all health information we maintain. A current copy of our Privacy Practices, with the most recent Revised / Effective Date, will be posted in our office for you to review. If we revise our Privacy Practices we will give you a revised copy on your next office visit after the revision takes place. If you have any questions about this Notice, please contact our office at (405) 751-3312.

OUR PLEDGE REGARDING MEDICAL INFORMATION

We 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 pertains to all the records of your care generated or obtained by our office. 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 or disclosure of medical information.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU

  1. Treatment. We may use protected information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, pharmacists, or other personnel involved in your care. For example, we may share information from our treatment records with your dentist so that he or she may make informed decisions concerning your ongoing care.
  2. Payment. We may use and disclose medical information about you for the purpose of claims management, billing, collections, and reimbursement. For example, we may need to give your health plan information about care provided by our office so your health plan will pay us or reimburse you for that care. We may also tell your health plan about treatments you are going to receive to obtain prior approval, or determine whether they will pay for a procedure.
  3. Health Care Operations. We use and disclose medical information about you for health care operations. For example, we may use medical information to review our treatment and services, and to evaluate the performance of our staff in caring for you.

WE MAY ALSO USE YOUR HEALTH INFORMATION FOR:

Appointment Reminders. We may use and disclose protected health information to contact you with a reminder that you have an appointment for medical care. We may disclose protected health information to a service that will contact you for such reasons. They have signed a Business Agreement with us stating how they will protect your privacy. You have the right to request that we contact you in specific ways, that are covered under Request Confidential Communications below.

Individuals Involved in Your Care or Payment for Your Care. Unless you object in writing, we may release medical information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. If you are unable or unavailable to agree or object, we will use our best judgment in communicating with your family and others.

Business Associates. We may disclose your PHI to business associates contracted to provide services to our office. Examples of business associates may include consultants, accountants, third-party billing companies and data processors. These business associates must give written assurance that they will safeguard your information.

Treatment Alternatives. We may use or disclose medical information to inform you about treatment alternatives that may be of interest to you.

Health-Related Products or Services. We may use and disclose medical information to tell you about our health-related products or services that may be of interest to you.

Worker's 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.

Military. If you are a member of the armed forces, we may disclose your PHI as required by military command authorities.

Inmates. If you are an inmate of a correctional institution or in the custody of a law enforcement official, we may release protected medical information about you to the correctional institution or law enforcement official. This release would be necessary: (1) for this practice to provide you with medical care; (2) to protect the safety and health of yourself or others; or (3) for the safety and security of the correctional institution.

Medical Examiners and Funeral Directors. We may release protected medical information to a medical examiner for purposes such as identification of a deceased person, or determination of a cause of death. We may also release protected medical information to funeral directors as necessary so that they may carry out their duties.

Organ and Tissue Donation. If you are an organ donor we may release protected medical information to an organ donation bank or similar organization as necessary to facilitate organ or tissue donation or transplantation.

Disaster Relief Effort. We may disclose 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.

To Avert a Serious Threat to Health or Safety. As required by law and the standards of ethical conduct, we may release your health information to the proper authorities if we believe, in good faith, that such release is necessary to prevent or minimize a serious threat to your or the public’s health or safety.

Limited Marketing. We may use your PHI to provide promotional items of nominal value or marketing information communicated to you face-to-face.

Research. Under certain circumstances, we may disclose your PHI to researchers whose clinical studies have been approved by an Institutional Review Board (“IRB”). While most clinical research studies require patient consent, there are some instances where your PHI may be used or disclosed when an IRB waiver has been given to the researchers, who must follow protocols to ensure the privacy of your health information.

Public Health Activities. We may be required to report your health information to authorities to help prevent or control disease, injury or disability. This may include the reporting of certain diseases, injuries, information of concern to the Food and Drug Administration, or information related to child abuse or neglect. We may also have to report to your employer certain work related illnesses and injuries so that your workplace can be monitored for safety.

Regulatory Agencies. We may disclose your health information to authorities for activities required by law, including, but not limited to, licensure, certification, audits, inspections and medical device reporting. We may provide your PHI to assist the government when it conducts an investigation or inspection of a health care provider or organization.

National Security / Protective Services. We may release protected information about you to authorized federal or state, or military command authorities so that they may carry out duties such as intelligence and security activities.

Lawsuits and Disputes. If you are involved in a lawsuit or dispute, we may disclose your PHI in response to a valid court or administrative order. In limited circumstances, we may disclose PHI in response to a subpoena, discovery request or other lawful process, when required by law.

Law Enforcement / As Required by Law. We may release protected information if requested to do so for reasons such as, but not limited to, in response to a court order or similar process; to identify or locate a criminal, fugitive, material witness or missing person; about a death we believe may be the result of criminal conduct; any criminal conduct involving our practice; or when otherwise required by local, state or federal law.

YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU

You have several rights with regard to your medical information. If you wish to exercise any of your rights, please contact our office at (405) 751-3312; or where required, submit your request in writing, in person or by mail to our office at:

Lester L. Cowden III D.D.S. & Emily M. Frye D.D.S.
Lakeside Oral Surgery, P.L.L.C.
3100 W. Britton Rd., Suite A
Oklahoma City, OK 73120
Attention: Privacy Officer

Specifically, you have the right to:

Inspect and copy your health information. You have the right to inspect and receive a copy of your health information. This includes medical and billing records, but does not include psychotherapy notes. In certain cases, such as with records involved in a court proceeding, or otherwise subject to law that limits your access to those records, your request may be denied. Your request must be in writing. We may charge you varying limited amounts for paper or electronic copies of records and images, such as clinical notes, billing, or x-rays.

Request to amend your health information. If you believe that your health information is incorrect or incomplete, you may ask us to correct the information. Your request must be submitted to us in writing, and you must tell us what you believe should be changed, and why it should be changed.

We may deny any request for amendment that is not in writing, or does not include a reason to support your request. In addition, we may deny your request if you ask us to amend information that:

  • Was not created by us;
  • Is not part of the medical information kept by our practice;
  • Is not part of the information that you would be permitted to inspect or copy; or
  • In our judgment is accurate and complete.

If we deny your request to amend, you may file a notice of disagreement with our office.

Request an accounting of disclosure. You have the right to ask us for a list of entities to whom we have disclosed your protected health information for reasons other than Treatment, Payment or Health Care Operations; or disclosures made pursuant to this Notice.

Your request must be in writing, and must specify the time period for which you are inquiring, which may not be longer than a six year period prior, and may not include dates before April 14, 2003. Your request should specify how you want to receive the list (such as on paper or on disk). The first list you request in each 12 month period will be free. For additional lists we may charge you the cost of providing the list. We will notify you of the cost involved, and you may choose to withdraw or modify your request at that time, before the costs are incurred.

Request restrictions on certain uses and disclosures. You have the right to ask for restrictions on how your health information is used, or to whom it is disclosed, even if the information pertains to Treatment, Payment, or Health Care Operation activities. You also have the right to request a limit on the protected health information we disclose about you to someone who is involved in your care or the payment for your care, such as a family member.

We will grant a request for restriction if:

  1. the disclosure is to a health plan for purposes of either payment or health care operations, and
  2. the PHI pertains to a service for which you have already paid in full out-of-pocket.

Otherwise, We are not required to agree to your request. If we do agree, we will comply with your request unless it is required to provide you with emergency treatment. Your request must be in writing, and must specify:

  1. What information you want us to limit;
  2. Whether you want to limit our use, disclosure, or both; and
  3. To who the restrictions will apply; for example, a family member.

Request confidential communications. You have the right to request that we communicate your health information to you in specific ways or places. For example, you may wish to receive information about your appointments through a text or email. We must accommodate reasonable requests. To request confidential communications, please notify our office and we will document your preference.

Obtain a paper copy of this Notice. Upon your request, you may at any time receive a paper copy of this Notice.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with us or with the Federal Department of Health and Human Services. If you have a complaint, please contact our office at (405) 751-3312 and we will provide you with the paperwork. You will not be penalized for filing a complaint.

CHANGES TO THIS NOTICE

We will abide by the terms of the Notice currently in effect. We reserve the right to change the terms of this Notice in response to new laws and regulations. We will provide you with the revised Notice at your first visit following the revision of the Notice.