HIPAA Notice



Saving Grace Pediatric Concierge

NOTICE OF PRIVACY PRACTICES This Notice is effective 5/14/2022

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.

Saving Grace Pediatric Concierge is required to provide you with this Notice of Privacy Practices under the federal Health Insurance Portability and Accountability Act (“HIPAA”). This Notice is also on our website at www.savinggracepeds.com

This Notice tells you about your rights about your health care records. You can ask the front desk representative for a copy of this Notice to keep for yourself. You can look at this copy anytime to see how we use your health care records and who gets to see them. A government rule requires that we give you something to sign at every visit that says you have read and understand this Notice. If you do not understand this Notice, please call our Privacy Officer at 405-590-0950 before you sign the form we give you.

We are allowed to change this Notice. If we change this Notice, it may change how we handle your medical records from new and old visits. The new Notice will be on our website.

Your record may be stored in one of our facilities or storage locations on paper or electronically. Your medical record may include information about how you were treated, results from tests you had, or decisions the doctor made about your care.

This Notice has four parts:

• What we must do to protect your medical records
• How we are allowed to use your medical records and who can see them without your
• permission
• Your rights about your medical records
• How you can contact us or the federal government if you have any problems with
• how we handle your medical record
• We Must:
• Keep your protected health information private
• Provide this Notice to you about what we must do to protect your health information
• and how your health information can be used and disclosed
• Follow the terms of this Notice

• Let you know about important changes in this Notice or any breach of unsecured health information

How We May Use Your Health Record

We may use your medical record in many ways without your permission. Some of these ways are listed below. Other uses and disclosures, including those for marketing purposes or constituting a sale, can only be made if you give us permission in writing. You can take back your permission at any time by contacting the Privacy Officer at the address below.

▶ Required Uses and Disclosures We must disclose your health record to you unless it would be harmful to you. We must also disclose your health record to the Department of Health and Human Services if they ask for it in an investigation related to how we protect patient health records. We will use or give your medical record to a government agency that asks for it by law. One example is for workers’ compensation claims.

▶ Treatment We will use your health information to treat you for the condition you are seeing us for and related services. This may include sharing your information with other doctors, specialists, hospitals, pharmacies and laboratories. We may also disclose your health information to take care of you in an emergency. We may call, email or write you about your visit, such as for an appointment reminder before you come in or for a follow up after you are seen. This may also be done by our Call Center. To do this, we will use the names, addresses, emails and phone numbers you give us. Unless you tell us not to, we may leave messages on answering machines, or send facsimiles, mail and email without calling you first. For example, we might leave a message on your answering machine for you to call us to talk about your lab results or treatment alternatives. We may also call your home and identify ourselves and ask an adult who answers the phone how a child we saw the day before is feeling. We may also call you at work if you give us the number. We will always use our reasonable judgment to comply with privacy rules about when and how we can communicate with you.

▶ Payment We will use your health information to receive payment for the services we provide to you. This means we may contact your insurance company to check the status of your policy or submit a claim for your visit. We will also include information about you and the services you received on bills we send to the person you tell us is responsible for your bill. For example, if your insurance company does not pay for your full visit, we may send a bill to your spouse that shows your name and address, the date you were seen, the services you received, your diagnosis, and the amount you owe. You have the right to restrict certain disclosures of your health information to a health plan where you pay out of pocket in full for the healthcare item or service.

▶ Health Care Operations We may use information about you in our offices for other reasons. This may include reviewing the quality of patient medical records and

training staff. We may also use information about you during your visit. For example, we may call your name when you are in the waiting area to tell you an exam room is ready. We may also contact you after your visit to ask you if you received good care or to let you know about health-related benefits and services you may be interested in, such as a flu shot clinic. We may also disclose information about you to our “business associates” who help perform important jobs for the Saving Grace Pediatric Concierge such as making appointments and sending bills to insurance companies. All of our business associates must follow all of the same rules we do to protect your health information.

▶ Parental Access Some states give the parent or legal guardian of a minor child or incapacitated patient rights about how we can use the patient’s health information. We will follow the federal law and the law of the state where the Saving Grace Pediatric Concierge is practicing. If one law is stricter than the other, we will use the stricter law.

▶ Public Health; Research We may disclose your health information to public health departments if the law allows them to get it. For example, they may need it to control disease, injury or disability; report abuse, neglect or domestic violence; report reactions to a medicine; or tell a person if they have been exposed to a harmful disease. We may also give your health information to a researcher if the law says we are allowed to.

▶ Legal Proceedings; Law Enforcement We may give out your health information if a judge or court official asks, such as with a subpoena. We may also give out your health information to law enforcement. For example, a police officer may need to know why you were seen if it is related to a criminal investigation or medical emergency.

▶ Disclosures Upon Death We may give out your health information to a coroner, medical examiner, funeral director, or cadaver organ, eye or tissue donation center if we are required to by law.

▶ Individuals Involved in Your Health Care Unless you tell us not to, we may tell a member of your family, relative, close friend or other person you choose about your protected health information if that person is involved in your care. We may also give information to someone who helps pay for your care. We may also give your information to the government or an agency that helps the government such as in the event of a disaster where medical care is needed.

▶ Your Rights Regarding Your Health Information You have the following rights about your medical record. If you think your rights have been violated, send a written note to the Privacy Officer at the address listed under “Contact Information” below. We may not agree to your request. If you think we should, you can ask us to review our decision.

▶ Right to See, Copy or Receive Your Record You can view your medical or billing record, or request a copy of it, for as long as we are required to keep your record. We may also utilize certain electronic systems, including an online patient portal maintained by our electronic medical records provider, to collect and store your information.

▶ Right to Ask for Restrictions You can ask us not to use any or all of your health information for your treatment or payment, or our healthcare operations. You must ask our Privacy Officer in writing and tell us (1) what information you want to protect, (2) whether you don’t want us to give it out, use it ourselves, or both, (3) who you want the restriction to apply to, and (4) when the restriction expires. We are not required to agree to your request. If we agree, we will protect the information you ask us to, unless it is needed for your emergency treatment. You can take back the restriction any time by writing to the Privacy Officer.

▶ Right to Tell Us How to Get In Touch You can ask us to call, email or send mail to you at a location other than your home. We will not ask you why and will accept your request if it is reasonable.

▶ Right to Ask for Changes to Your Record If you think information in your health record is wrong or missing, you can ask us to change it for as long as we have it in our files. Send your request in writing to the Privacy Officer. We are not required to agree to your request.

▶ Right to Know Who Has a Copy of Your Record You can ask us for a list of who we have given a copy of your record to that did not get it for purposes of treatment, payment or our health care operations. For example, the following people do not have to be on the list: you, your family members or friends who cared for you, other medical providers who cared for you, your insurance companies or our business associates. The list applies to people who received your record after May 14, 2022 and no more than six years before your request. There may be other limits on getting this list from us.

▶ Right to Have a Copy of this Notice You can get a copy of this notice online at SavingGracePeds.com or from the Privacy Officer at the address or phone number listed below.

▶ Complaints If you think your privacy rights have been violated, send a complaint in writing to our Privacy Officer or the Secretary of the United States Department of Health and Human Services in Washington, D.C. We will not penalize you for filing a complaint.

▶ Contact Information You may contact our Privacy Officer by mail at 3000 W. Memorial Rd. Box 438 Oklahoma City, OK 73120 and by telephone at (405) 590-0950

Print Name: _________________________________________ Date: _______________ Signature: __________________________________________