Patient Information Confidentiality and Privacy Notice

Effective Date: 4/14/2003

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.

If you have any questions about this notice, please contact any Receptionist at (405) 273-5801.

WHO WILL FOLLOW THIS NOTICE:

This notice describes the Shawnee Medical Center Clinic's and the AM PM Clinic's practices and that of:

Any health care professional authorized to enter information into your file or record. All employees, staff and other personnel.

All associating entities, sites and locations of the Shawnee Medical Center Clinic and the AM PM Clinic follow the terms of this notice. In addition, these entities, sites and locations may share medical information with each other for treatment, payment or clinic operation purposes described in this notice.

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 applies to all of the records of your care.

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 and disclosure of medical information.

We are required by law to:

• Make sure that medical information that identifies you is kept private;
• Give you this notice of our legal duties and privacy practices with respect to protected medical information about you; and
• Follow the terms of the notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE YOUR MEDICAL INFORMATION:

The following categories describe different ways that we use and disclose protected medical information. For each category of uses or disclosures we will explain what we mean. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

For Treatment: We may use protected medical information about you to provide you with medical treatment or services. We may disclose protected medical information about you to doctors, nurses, technicians, pharmacists, or other personnel who are involved in taking care of you. Different departments of our practice also may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work, and x-rays. We also may disclose protected medical information about you to people outside the practice who may be involved in your medical care, such as family members or others we use to provide service, that are part of your care.

For Payment: We may use and disclose protected medical information about you so that the treatment and services you receive may be billed to and payment may be collected from you, an insurance company, or a third party. For example, we may need to give your health plan information about treatment you received so your health plan will pay us or reimburse you. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. We also may use and disclose your information to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your information to bill you directly for services and items.

Appointment Reminders: We may use and disclose protected medical information to contact you as a reminder that you have an appointment for treatment or medical care.

Treatment Alternatives: We may use and disclose protected medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Health-Related Benefits and Services: We may use and disclose protected medical information to tell you about health-related benefits or services that may be of interest to you.

Individuals Involved in Your Care or Payment for Your Care: We may release protected medical information about you to a friend or family member who is involved in your medical care. We may also give information about your condition to someone such as a family member or friend who helps pay for your care. In addition, we may disclose protected medical 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.

Research: Under certain circumstances, we may use and disclose minimally necessary medical information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of medical information, trying to balance the research needs with patients' need for privacy of the medical information. Before we use or disclose medical information for research, the project will have been approved through this research approval process, but we may, however, disclose medical information about you to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs. We will almost always ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care in our practice.

As Required By Law: We will disclose minimally necessary protected medical information about you when required to do so by federal, state or local law.

To Avert a Serious Threat to Health or Safety: We may use and disclose minimally necessary protected medical information about you when necessary to prevent a serious threat to your health and safety of the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

SPECIAL SITUATIONS:

Organ and Tissue Donation: If you are an organ donor, we may release minimally necessary protected medical information about you to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

Military and Veterans: If you are a member of the armed forces, we may release minimally necessary protected medical information about you as required by military command authorities. We may also release protected medical information about foreign military authority, if you are in their service.

Workers' Compensation: We may release minimally necessary protected medical information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness. The release of such information is controlled by state and/or federal law.

Public Health Risks: We may disclose minimally necessary protected medical information about you for public health activities. These activities generally include the following:

• To prevent or control disease, injury or disability;
• To report births and deaths;
• To report child abuse or neglect;
• To report vulnerable adult abuse;
• To report reactions to medications or problems with products;
• To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; or
• To notify the appropriate government authority if we believe a patient has been the victim of domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

Health Oversight Activities: We may disclose minimally necessary protected medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose minimally necessary protected medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement: We may release minimally necessary protected medical information about you if asked to do so by a law enforcement official:

• In response to a court order, subpoena, warrant, summons or similar process;
• To identify or locate a suspect, fugitive, material witness, or missing person;
• About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement;
• About a death we believe may be the result of criminal conduct;
• About criminal conduct involving our practice; and
• In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

Medical Examiners and Funeral Directors: We may also release minimally necessary protected medical information about you to a medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release minimally necessary protected medical information about patients to funeral directors as necessary to carry out their duties.

National Security and Intelligence Activities: We may release minimally necessary protected medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Protective Services for the President and Others: We may disclose protected information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.

Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release minimally necessary 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 health care; (2) to protect you health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU:

You have the following rights regarding protected medical information we maintain about you:

Right to Inspect and Copy: You have the right to inspect and copy medical information that may be used to make decisions about you care. Usually, this includes medical and billing records, but does not include psychotherapy notes.

To inspect and/or copy medical information you must submit your request to the Health Information Department in our office. If you request a copy of the information, we may charge a fee for the costs of retrieving, copying, mailing, and any other supplies associated with your request.

Right to Amend: If you feel that any of the medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by our practice.

To request an amendment, your request must be made in writing and submitted to the Health Information Department in our office. In addition, you must provide a reason that supports your amendment request.

WE MAY DENY YOUR REQUEST FOR AN AMENDMENT IF IT IS NOT IN WRITING OR DOES NOT INCLUDE A REASON TO SUPPORT THE REQUEST. IN ADDITION, WE MAY DENY YOUR REQUEST IF YOU ASK US TO AMEND INFORMATION THAT:

• Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
• Is not part of the medical information kept by our practice;
• Is not part of the information which you would be permitted to inspect and copy; or
• In our judgment is accurate and complete as it appears or as it was at the time it was originally captured and recorded.

Right to an Accounting of Disclosures: You have the right to request an "accounting of disclosures." This is a list of the disclosures we have made of your medical information. We are not required to account for routine disclosures.

To request this accounting of disclosures, you must submit your request in writing, to the Health Information Department in our office. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. The first accounting you request within a twelve-month period will not include a cost for providing the disclosure list. For additional accountings, we may charge you for the costs 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 any costs are incurred.

Right to Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work, or at home, or by mail, or by phone, or by E-mail.

To request confidential communications, you must make your request in writing to the Health Information Department in our office. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Copy of This Notice: You have the right to a copy of this notice. You may ask us to give you a copy of this notice at any time.

(You may obtain a copy of this notice at our website, www.smcclinic.com)

Right to Request Restrictions: You have the right to request a restriction or limitation on the protected medical information we use or disclose about you for treatment, payment or health care operations. However, we must receive your restrictions in writing before we have made such disclosures. Also, if you restrict our right to use your protected medical information for treatment, payment or health operations, we reserve the right to immediately withdraw our services from you and terminate the physician-patient relationship.

You also have the right to request a limit on the protected medical information we disclose about you to someone who is involved in your care or the payment for your care, such as a family member or friend. For example, you could ask that we not use or disclose information about a surgery to your family.

We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

To request restrictions, you must make your request in writing to the Health Information Department in our office. In your request restrictions, you must 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, for example, disclosures to your spouse.

CHANGES TO THIS NOTICE:

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for protected medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in our facility. The notice will contain on the first page, in the right-hand corner, the effective date. In addition, each time you are in our facility for treatment or health care services, we will offer you a copy of the current notice in effect.

COMPLAINTS:

If you believe your privacy rights have been violated, you may file a complaint with our facility or with the Secretary of the Department of Health and Human Services. To file a complaint with our facility, contact the Privacy Officer at (405) 273-5801 Ext. 3333. All complaints must be submitted in writing.

You will not be penalized for filing a complaint.

OTHER USES OF MEDICAL INFORMATION:

Other uses and disclosures of protected medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose protected medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose protected medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.