Privacy/HIPAA

Francois J. du Toit, M.D.

4411 W Gore Blvd. Ste B-6
Lawton, OK 73505
580-699-7500

NOTICE OF PRIVACY PRACTICES

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 goal is to take appropriate steps to attempt to safeguard any medical or other personal information that is provided to us. The Privacy Rule under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires us to: (1) maintain the privacy of medical information provided to us; (2) provide notice of our legal duties and privacy practices; and (3) abide by the terms of our Notice of Privacy Practices currently in effect.

WHO WILL FOLLOW THIS NOTICE

This notice describes the practices of our physicians, employees and staff. This notice applies to each of these individuals. In addition, these individuals may share medical information for treatment, payment and health care operation purposes described in this notice.

INFORMATION COLLECTED ABOUT YOU

In the ordinary course of receiving treatment and health care services from us, you will be providing us with personal information such as:

• Your name, address, phone number, date of birth and social security number
• Information relating to your medical history
• Your insurance information and coverage
• Information concerning other doctors and health care providers
• Your email address and other phone numbers to reach you
• Financial information in regards to payment of fees

In addition, we will gather certain medical information about you and will create a record of the care provided to you. Some information also may be provided to us by other individuals or organizations that are part of your "circle of care" such as specialists, other doctors, your health plan, and family members. HOW WE MAY USE AND DISCLOSE INFORMATION ABOUT YOU We may use and disclose personal and identifiable health information about you for a variety of purposes. All of the types of uses and disclosures of information are described below, but not every use or disclosure in a category is listed.

USES AND DISCLOSURES OF MEDICAL INFORMATION

Required Disclosures We are required to disclose health information about you to the Secretary of Health and Human Services, upon request, to determine our compliance with HIPAA and to you, in accordance with your right to access and right to receive an accounting of disclosures, as described below.

For Treatment We may use or disclose your medical information to a doctor or other health care provider in order to provider treatment to you.

For Payment We may use and disclose health information about you to bill for our services and to collect payment from you or your insurance company. For example, we may need to give a payer information about your current medical condition so that it will pay us for our services that we have furnished you. We may also need to inform your payer of the treatment you are going to receive in order to obtain prior approval or to determine whether the service is covered.

For Health Care Operations We may use and disclose information about you in connection with our health care operations. For example, we sometimes arrange for auditors or other consultants to review our practices, evaluate our operations, and tell us how to improve our services. Or, for example, we may use and disclose your health information to review the quality of services provided to you.

On your Authorization You may give us a written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect.

Public Benefit There are a number of public policy reasons why we may disclose information about you, which are described below:

• We may disclose protected health information (PHI) about you when we are required to do so by federal, state, or local law.
• We may disclose protected health information about you in connection with certain public health reporting activities including disease and vital statistics, child abuse reporting, FDA oversight, and to employers regarding work-related illness or injury.
• We may disclose a patient's PHI where we reasonably believe a patient is a victim of abuse, neglect or domestic violence and the patient authorizes the disclosure or it is required by law.
• We may disclose PHI about you in connection with certain health oversight activities of licensing and other health oversight agencies, which are authorized by law.
• We may disclose you PHI as required by law, including in response to a warrant, subpoena, or other order of a court or administrative hearing body or to assist law enforcement identify or locate a suspect, fugitive, material witness or missing person.
• We may release a patient's PHI (1) to a coroner or medical examiner to identify a deceased person or determine the cause of death and (2) to funeral directors. We may also release your PHI to organ procurement organizations, transplant centers, and eye or tissue banks, if you are an organ donor.
• We may release your PHI to worker's compensation or similar programs, which provide benefits for work-related injuries or illnesses without regard to fault. Health information about you also may be disclosed when necessary to prevent serious threat to your health and safety or the health and safety of others.
• We may use or disclose certain health information about your condition and treatment in connection with certain research activities.
• We may disclose PHI to the military and to federal officials for lawful intelligence, counterintelligence, and national security activities.
• We may disclose PHI for legal or administrative proceedings that involve you. We may release information upon order of a court or administrative tribunal. We may also release PHI in the absence of such an order and in response to a discovery or other lawful request, if efforts have been made to notify you or secure a protective order.
• If you are an inmate, we may release PHI about you to a correctional institution where you are incarcerated or to law enforcement officials in certain situations such as where the information is necessary for your treatment, health or safety, or the health and safety of others.

Health Related Services We may use your PHI to contact you with information about health-related benefits and services or about treatment alternatives that may be of interest to you. We may disclose your PHI to a business associate to assist us in these activities. We may use your information to contact you as a reminder that you have an appointment or that you should schedule an appointment. We may contact you at any and all telephone numbers and email addresses you provide, unless you provide a written request directing no contact at a specific number or email address. We may leave a message with a person or voice mail to call our office or to confirm an upcoming appointment on a certain date and time at any and all telephone numbers provided, unless you provide a written request directing no contact at a specific number or email addresses.

Business Associates We may disclose your PHI to a business associate to help up carry out our health care activities and functions. Our business associates must promise that they will respect the confidentiality or your personal and identifiable health information.

Disclosures to Persons Assisting in Your Care or Payment for Your Care We may disclose information to individuals involved in your care or in the payment for your care. This includes people and organizations that are part of your "circle of care" such as your spouse, your other doctors, or an aide who may be providing services to you.

Research We may obtain, create, use and/or disclose individually identifiable health information. We may use and disclose for research purposes your PHI that has been de-identified. We may use and disclose your PHI without an authorization in certain circumstances.

INDIVIDUAL RIGHTS

• You have the right to ask for restrictions on the ways we use and disclose your health information. We will consider your request, but we are not required to accept it.
• You have the right to request that you receive communications containing your PHI from us by alternative means or at alternative locations. For example, you may ask that we only contact you at home or by mail. You must make your request in writing
• Except under certain circumstances, you have the right to inspect and copy medical, billing and other records used to make decisions about you. You must make a request in writing to obtain access to your health information. If you ask for copies of this information, we may charge you a fee for copying and mailing.
• If you believe that information in your records in incorrect or incomplete, you have the right to ask us to correct the existing information or add missing information. Your request must be in writing, and it must explain why the information should be amended. Under certain circumstances, we may deny your request, such as when the information is accurate and complete.
• You have the right to receive a list of certain instances when we have used or disclosed your health information. We are not required to include in the list uses and disclosures for your treatment, payment for services furnished to you, our health care operations, disclosures to you, disclosures you give us authorization to make and uses and disclosures before April 14, 2003, among others. If you ask for this information from us more than once every twelve months, we may charge you a fee.
• You have the right to a copy of this notice. You may ask us for a copy at any time.

To exercise any of your rights, please contact us in writing at:

Francois J. du Toit, M.D.

4411 W Gore Blvd. Ste B-6
Lawton, OK 73505
580-699-7500

Changes to this Notice We reserve the right to make changes to this notice at any time. We reserve the right to make the revised notice effective for PHI we have about you as well as any information we receive in the future. In the event there is a material change to this notice, the revised notice will be posted. In addition, you may request a copy of the revised notice at any time.

Complaints/Comments If you have any complaints concerning our privacy practices, you may contact us at Francois J. du Toit, M.D. , 4411 W Gore Blvd. Ste B-6, Lawton, OK 73505. 580-699-7500. You may also submit a written complaint to the US Department of Health and Human Services. We will provide you with the address to file your comments with the US 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 US Department of Health and Human Services.

This notice is effective as of July 1, 2003.