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Oklahoma Pain Physicians

Rafael Justiz, M.D., FIPP, DABIPP

The document immediately following this is our Notice of Privacy Practices. We have prepared this summary to assist you in understanding the notice. For the full and complete description of our practices, please read the full notice.

What is a Notice of Privacy Practices?

It is a formal document that describes how your medical information is used by our staff and disclosed to others. It also describes your privacy rights.

Why was I provided this document?

We take great care in treating you and your medical information with respect and confidentiality. A federal law now requires us to notify you of our privacy practices in a more structure format.

How is my medical information used?

· To plan and carry out your treatment

· To submit claims to your insurance

· To enable us to carry out health care options

Are there circumstances where my information is used without my prior permission?

· Public health and other safety issues

· Requirements by State, Federal and local law

· Law Enforcement

· Certain types of research

What are my rights described in the notice?

· To review or copy your medical records

· To request an amendment to your medical information

· To receive an accounting disclosures of your medical information

· To request a restriction in how we disclose your medical information

· To have us communicate with you in a certain way or at a certain location

· To make a complain about privacy issues

· To authorize other releases of your medical information

Who will follow this notice?

· Our employees, volunteers, students and trainees

· Other health care and service providers that provide care or services at this entity

Who doesn’t this notice cover?

Independent physician practices or operations of health care and service providers that provide services independent of the entity

What is I have questions about it later?

Please contact the Privacy officer of this entity


Oklahoma Pain Physicians is required to maintain the privacy of your protected health information and to provide you with a notice of our privacy practices. Protected health information (hereafter referred to as “PHI”) is information that individually identifies you and pertains to your past, present, or future health status. Oklahoma Pain Physicians and the individual members of its professional staffs are providing you with a joint Notice with respect to services provided by Oklahoma Pain Physicians. We will not use or disclose your PHI except as described in this Notice. With some exceptions, we may not use or disclose any more of your PHI than is necessary to accomplish the purpose of the use or disclosure. This Notice applies to all PHI generated or maintained by Oklahoma Pain Physicians.

Treatment: We may use your PHI to provide you with medical treatment and services. We may disclose your PHI to physicians, nurses, technicians, medical students, and other health care personnel who need to know your PHI for your care and continued treatment. Such information may be contained in a Regional Health Information Organization (“RHIO”). Different hospital departments may share your PHI in order to coordinate services, such as prescriptions, lab work, x-rays and other services. For example, your physician may need to tell the dietitian if you have diabetes so we can arrange appropriate meals.

Payment: We may use and disclose your PHI for the purpose of determining coverage, billing, collections, claims management, medical data processing, and reimbursement. PHI may be released to an insurance company, third party payer or other entity (or their authorized representatives) involved in the payment of your medical bill and may include copies or excerpts of your medical record that are necessary for payment of your account. For example, a bill sent to a third party payer may include information identifying you, your diagnosis, and procedures and supplies used. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or determine whether your plan will cover the treatment.

Health Care Operations: We may use and disclose your PHI during health care operations. These uses and disclosures are necessary to run the hospital and make sure our patients receive quality care. Common examples include conducting quality assurance, performance improvement, utilization review, medical review, peer review, internal auditing, investigation of complaints, accreditation, certification, licensing, credentialing, medical research, training and education.

Emergencies: Your authorization is not required if you need emergency treatment. We will try to get your authorization as soon as practicable after the emergency.

Mental Health/Substance Abuse: In certain circumstances, we may not disclose your PHI, including psychotherapy notes, to you without the written consent of your physician or to others without your written authorization or a court order.

Family/Friends/Caregivers: Unless you object in writing, we may disclose your PHI to a friend, family member or other caregiver who is involved in your medical care or who helps pay for your care. We may also tell your family or friends about your location of care, general condition or death. We may disclose your PHI to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location. If you are unable or unavailable to agree or object, we will use our best judgment in communicating with your family and others.

Inpatient Hospital Directories/Clergy: Unless you object in writing, we may include certain limited information about you in a hospital directory while you are a patient at a hospital. This information may include your name, location in the hospital, your general condition (e.g., fair, stable, etc.) and your religious affiliation. This is so your family and friends can visit you and generally know how you are doing. The directory information, except for your religious affiliation, may also be released to people who ask for you by name. Your name or religious affiliation may be given to a member of the clergy affiliated with the hospital or a member of the community clergy, such as a priest or rabbi, who asks for you by name or by religious affiliation.

Appointment Reminders: We may use and disclose your PHI to contact you as a reminder that you have an appointment for treatment or medical care. This may be done through an automated system or by one of our staff members. If you are not home, we may leave a message on an answering machine or with the person answering the telephone.

Health-Related Business and Services: We may use and disclose your PHI to tell you of health-related products, benefits or services related to your treatment, case management, care coordination, or alternative treatments, therapies, providers or care settings.

Business Associates: We may disclose your PHI to business associates with whom we contract to provide services on our behalf. Examples of business associates include copy services used to copy medical records, consultants, accountants, lawyers, medical transcriptionists and third-party billing companies. We will only make these disclosures if we have received satisfactory assurance that the business associate will properly safeguard your PHI.

Research: Under certain circumstances, we may use and disclose your PHI to researchers whose clinical research 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 pursuant to IRB waiver or as required or permitted by law. PHI regarding people who have died may be disclosed without authorization in certain circumstances.

Limited Data Set: If we use your PHI to make a "limited data set," we may give the “limited data set” that includes your information to others for the purposes of research, public health action or health care operations. The persons who receive "limited data sets" are required to agree to take reasonable steps to protect the privacy of your medical information.

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

Workers’ Compensation: We may disclose your PHI for workers’ compensation or similar programs in order to comply with workers’ compensation and similar laws.
Organ and Tissue Donation: We are required by federal law and accreditation standards to notify organizations that handle organ procurement, eye or tissue transplantation, and other entities engaged in the procurement, banking or transplantation of organs whenever there is a death in our facility. This is to facilitate organ or tissue donation and transplantation.

Regulatory Agencies: We may disclose your PHI to a health oversight agency for activities required or permitted by law, including, but not limited to, licensure, certification, audits, investigations, 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.

Law Enforcement: We may disclose your PHI if asked to do so by law enforcement: (1) when we receive a court order, warrant, summons or other similar process; (2) to identify or locate a suspect, fugitive, material witness, or missing person; (3) when the patient is the victim of a crime, if we are unable to obtain the person’s agreement; (4) when we believe the patient’s death may be the result of criminal conduct; (5) about criminal conduct at the hospital; and (6) in emergency circumstances to report a crime, the location of a crime or victims, or the identity, description or location of the person who committed the crime.

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.

Public Health: As required or permitted by law, we may disclose your PHI to public health (including social service or protective services agencies) or legal authorities charged with preventing or controlling disease, injury or disability.

Judicial and Administrative Proceedings: We may disclose your PHI in the course of any administrative or judicial proceeding.

Specific Government Functions: We may disclose your PHI to military personnel and veterans in certain situations. We may disclose your PHI for national security purposes, such as protecting the President of the United States or conducting intelligence operations.

Military/Veterans: We may disclose your PHI as required by military command authorities, if you are a member of the armed forces.

Inmates: If you are an inmate of a correctional institute or under the custody of a law enforcement officer, we may release your PHI to the correctional institute or law enforcement official.

Health & Safety: In order to avoid a serious threat to the health and safety of a person or the public, we may disclose PHI to law enforcement personnel or persons able to prevent or lessen such harm. We may notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition as ordered by public health authorities or allowed by state law.

Required by Law: We will disclose your PHI when required or permitted to do so by federal, state, or local law. For example, we are required to report criminally injurious conduct.

Coroners, Medical Examiners, Funeral Directors: We may release your PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or to determine a cause of death. We may also release your PHI to funeral directors as necessary to carry out their duties.

Any Other Uses: We must obtain a separate authorization from you to use or disclose your PHI for situations not described in this Notice.

Fundraising: We may use your demographic information (name, address, telephone, age, etc.) and the dates of your health care to contact you about fundraising programs. We may disclose this information to a business associate or foundation to assist us in fundraising efforts. We will provide you with fundraising materials and a description of how you may opt out of future communications.

Note: If you do not want to be contacted for fundraising efforts, you must notify the Oklahoma Pain Physicians Privacy Officer in writing at the address shown at the bottom of this Notice.


Although all records concerning your treatment at an Oklahoma Pain Physicians facility are the property of Oklahoma Pain Physicians, you have the following rights concerning your PHI.

Right to Confidential Communications: You have the right to receive confidential communications of your PHI by alternative means or at alternative locations. For example, you may request that we only contact you at work or by mail. You must submit your request in writing and identify how or where you wish to be contacted. We will accommodate all reasonable requests.

Right to Inspect and Copy: You have the right to inspect and copy your PHI as provided by law. This right does not apply to psychotherapy notes. Your request must be made in writing. We have the right to charge you the amounts allowed by state or federal law for such copies. We may deny your request to inspect and copy in certain circumstances. If you are denied access, you may request that the denial be reviewed. A licensed health care professional chosen by us will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Right to Amend: If you feel that the PHI we have about you is incorrect or incomplete, you have the right to request an amendment of your PHI. You must submit your request in writing and state the reason(s) for the amendment. We may deny your request for an amendment if (1) the request is not in writing or does not include a reason to support the request; (2) the information was not created by us or is not part of the medical record that we maintain; (3) the information is not part of the information that you would be permitted to inspect or copy; or (4) the information is accurate and complete. If we deny your amendment, you have a right to file a statement of disagreement with our Privacy Officer.

Right to an Accounting: You have the right to obtain a statement of certain disclosures of your PHI to third parties, except those disclosures made for treatment, payment or health care operations, authorized by you or pursuant to this Notice. To request this list, you must submit your request in writing and provide the specific time period requested. You may request an accounting for up to six (6) years prior to the date of your request (three years if PHI is an electronic health record). If you request more than one (1) accounting in a 12-month period, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to modify or withdraw your request before any costs are incurred.

Right to Request Restrictions on Disclosure(s): You have the right to request restrictions or limitations on PHI we use or disclose about you unless our use or disclosure is required or permitted by law. Any agreement to additional restrictions must be in writing and signed by a person authorized to make such an agreement on our behalf. To request restrictions, you must make your request in writing and tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply. 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. We are not required to honor other requests. However, if we agree, we will comply with your request unless the information is needed to provide emergency treatment to you.

Right to Revoke Authorization: You have the right to revoke your authorization to use or disclose your PHI, EXCEPT to the extent that action has already been taken by us in reliance on your authorization.

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 its Notice and to make the new Notice provisions effective for all PHI we maintain. We will provide you with the revised Notice at your first visit following the revision of the Notice.

OWNERSHIP CHANGE: In the event that an Oklahoma Pain Physicians is sold or merged with another organization, your PHI may become property of the new owner.


If you believe your privacy rights have been violated, you may call 405-527-2220 or you may file a complaint with our Privacy Officer.

You may also report a privacy rights violation to the Secretary of the Department of Health and Human Services, 200 Independence Avenue, S.W., Washington, D.C. 20201. All complaints must be in writing and filed within 180 days of when you knew or should have known that the act or omission complained of occurred. You will not be penalized for filing a complaint.