Dental Implant Center of Oklahoma
5522 S. Lewis Ave., Tulsa, OK 74105
(918) 906-2525
Notice of Privacy Practices
This notice is to inform you that your personal health information will only be used for purposes of
treatment in our facility and will not be misused or disclosed by / to anyone outside of our practice. You
may gain access to this information if you desire.
Please review it carefully. The privacy of your health information is important to us.
Our Legal Duty
We are required by applicable federal and state law to maintain the privacy of your health information.
We are also required to give you this notice about our privacy practices, our legal duties, and your rights
concerning your health information. We must follow the privacy practices that are described in this notice
while it is in effect. This notice takes effect on April 14, 2003 and will remain in effect.
We reserve the right to change our privacy practices and the terms of this notice at any time provided such
changes are permitted by applicable law. We reserve the right to make the changes in our privacy
practices and the new terms of our notice effective for all health information that we maintain, including
health information we created or received before we made the changes. Before we make a significant
change in our privacy practices, we will change this notice and make the new notice available upon
request.
You may request a copy or our notice at any time. For more information about our privacy practices, or
for additional copies of this notice, please contact us using the information listed at the end of this notice.
Uses and Disclosures of Health Information
We use and disclose health information about you for treatment, payment, and healthcare operations. For
example:
- Treatment: We may use or disclose your health information to a physician or other healthcare provider who is currently providing treatment to you.
- Payment: We may use and disclose your health information to obtain payment for services we provide to you (i.e. insurance companies).
- Healthcare Operations: We may use and disclose your health information in connection with our
healthcare operations. Healthcare operations include quality assessment and improvement activities,
reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and
provider performance, conducting training programs, accreditation, certification, licensing or
credentialing activities.
Your Authorization
You may give us written authorization to use your health information or to disclose it to anyone for any
purpose (e.g. a family member picking up records, referral to dental specialist, etc.) If you give us an
authorization, you may revoke it in writing at any time. Your revocation will not affect any use or
disclosure permitted by your authorization while it was in effect. Unless you give a written authorization,
we cannot use or disclose your health information for any reason except those described in this notice.
To Your Family and Friends
We must disclose your health information to you, as described in the Patient Rights section of this Notice.
We may disclose your health information to a family member, friend or other person to the extent
necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we
may do so.
Persons Involved in Care
We may use or disclose health information to notify, or assist in the notification of (included identifying
or locating) a family member, your personal representative or another person responsible for your care, of
your location, your general condition, or death. If you are present, then prior to use or disclosure or your
health information, we will provide you with an opportunity to object to such uses of disclosures. In the
event of your incapacity or emergency circumstances, we will disclose health information based on a
determination using our professional judgment disclosing only health information that is directly relevant
to that person’s involvement in your healthcare. We will also use our professional judgment and our
experience with common practice to make reasonable inferences of your best interest in allowing a person
to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.
Marketing Health-Relation Services: Our dental office does not use patient information for any
marketing purposes. We will not use your health information for marketing communications without your
written authorization.
Required by Law: We may use or disclose your health information when it is required by law to do so
(i.e. missing person, etc.)
Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably
believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of
other crimes. We may disclose your health information to the extent necessary to avert a serious threat to
your health or safety or the health or safety of others.
National Security: We may disclose to military authorities the health information of Armed Forces
personnel under certain circumstances. We may disclose to lawfully authorize federal official’s health
information required by lawful intelligence, counterintelligence, and other national security activities. We
may disclose to correctional institutions or law enforcement officials having lawful custody of protected
health information of inmate or patient under certain circumstances.
Appointment Reminders: We may use or disclose your health information to provide you with
appointment reminders (such as voicemail messages, postcards, or letters).
Patient Rights
Access: You have the right to look at or get copies of your health information, with limited exceptions.
You may request that we provide copies in a format other than photocopies. We will use the format you
request unless we cannot practicably do so. You must make a request in writing to obtain access to your
health information. You may obtain a form to request access by using the contact information listed at the
end of this notice. We may charge you a reasonable cost-based fee for expenses such as copies and staff
time. You may request access by sending us a letter to the address at the end of this notice. If you request
an alternative format, we will charge a cost-based fee for providing your health information in that
format. If you prefer, we will prepare a summary or an explanation of your health information for a fee.
Contact us using the information listed at the end of this notice for a full explanation of our fee structure.
Disclosure Accounting: You have the right to receive a list of instances in which we or our business
associates disclosed your health information for any purpose, other than treatment, payment, healthcare
operations and certain other activities, for the last 6 years, but not before April 14, 2003. If you request
this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for
responding to these additional requests.
Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we
will abide by our agreement except in an emergency.
Alternative Communication: You have the right to request that we communicate with you about your
health information by alternative means or to alternative locations. You must make your request in
writing. Your request must specify the alternative means or locations, and provide satisfactory
explanation how payments will be handled under the alternative means or location you request.
Amendment: You have the right to request that we amend your health information. Your request must be
in writing. It must explain why the information should be amended. We may deny your request under
certain circumstances.
Questions and Complaints:
If you desire further information about our privacy practices or if you have questions, please contact us.
If you are concerned that 1) we may have violated your privacy right, 2) you disagree with a decision we
made about access to your health information, 3) in response to a request you made to amend or restrict
the use or disclosure of your health information or 4) to have us communicate with you by alternative
means or at alternative locations, you may complain to us using the contact information listed at the end
of this notice. You also may submit a written complaint to the U.S. Department of Health and Human
Services. We will provide you with the address to file your complaint with the U.S. Department of Health
and Human Services upon request.
We support your right to the privacy of your health information. We will not retaliate in any way if you
choose to file a complaint with us or with the U.S. Department of Health and Human Services.
Contact Officer: Chris Ward DDS, Privacy Officer, Owner
Telephone: (918) 906-2525
Address: 5522 S Lewis Ave
Tulsa, Oklahoma 74105