Effective Date: April 14, 2003


This healthcare operation creates a record of the care and services you receive. Your medical records and billing information are created and retained in our computer system. The computer system is accessible to select personnel and members of the medical staff only. Proper safeguards are in place to discourage improper use or access. We are required by law to protect your privacy and the confidentiality of your personal and protected health information and records. This notice describes your rights and our legal duties regarding your protected health information. The entities covered by this Notice include the clinic and all health care providers practicing here along with their support staffs.

Definitions: You, at times may see or hear new terms in relation to this Notice. Some of the terms you may hear and their definitions are:

1. Protected Health Information (PHI). Your personal and protected health information we use to render care to you and bill for services provided.

2. Privacy Officer. The individual with responsibility for developing and implementing all policies and procedures concerning your PHI and receiving and investigating any complaints you may have about the use and disclosure of your PHI.

3. Business Associate. An individual or business outside of our organization, working with our organization, to help provide you with healthcare services.

4. Authorization. We will obtain an authorization from you giving us permission to use or disclose your PHI for purposes other than for your treatment, to obtain payment of your bills, and for healthcare operations of the clinic.

5. Organized Health Care Arrangement. This clinic and the healthcare providers practicing here are part of an integrated care setting in which your PHI will be shared for purposes of treatment, payment, and healthcare operations.

Use and Disclosure of Your PHI. This clinic may use and disclose your PHI for the following:

1. Treatment. We may use your PHI to provide you with mental health treatment.  An example would be providing your mental health records to the Department of Human Services in order to facilitate adoption.  We may also have to make available your mental health records to a psychiatrist in order to help you with receiving medications.

2. Payment. 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.

3. Referral Sources.  We are required to share any of your PHI to your guardian, if you are not your own guardian.  We will share your PHI only when requested. 

4. Children’s Court and Department of Human Services.  If you or your children are in DHS custody, your child’s Caseworker is the temporary court appointed guardian.  We are also going to supply requested information, when asked to, with the Judge handling your case.

5. Appointment Reminders. We may use and disclose your PHI to contact you as a reminder you have an appointment for treatment or medical care. This may be done by one of our staff members. If you are not at the number you provided for contact, we could leave this information on your answering machine or in a message left with the person answering the telephone.

6. Health Related Benefits and Services. We may use and disclose your PHI to tell you about health-related benefits or services, or recommend possible treatment options or alternatives of possible interest to you.

7. Individuals Involved in Your Care or Payment for Your Care. We may release your PHI to a friend or family member who is involved in your medical care. We may also give your PHI to someone who helps pay for your care. We may also disclose your PHI to an entity assisting in a disaster relief effort so your family can be notified about your condition, status and location.

8. In the case of a minor (under 21 years of age), or in the case you are not your own guardian, your PHI may be supplied to your guardian upon their request.

9. As Required by Law. We will disclose your PHI when required to do so by federal, state or local law.

10. To Avert a Serious Threat to Health or Safety. We may use and disclose your PHI when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure would only be to someone able to help prevent the threat.

11. Organ and Tissue Donations. If you are an organ donor, we may release your PHI to organizations handling organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

12. Military. If you are a member of the armed forces, we may release your PHI as required by military command authorities. We may also release PHI about foreign military personnel to the appropriate foreign military authority.

13. Workers Compensation. We may release your PHI for workers compensation, disability or similar programs as authorized by state laws for the provision of benefits for work-related injuries or illness.

14. Public Health Risks. We may disclose your PHI for public health activities to, for example:
· Prevent or control disease, injury or disability;
· Report births and deaths;
· Report child abuse or neglect;
· Report reactions to medications or problems with products;
· Notify people of recalls of products they may be using;
· 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;
· Notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence, if you agree or when required by law.

15. Health Oversight Activities. We may disclose PHI to a health oversight agency for activities necessary for the government to monitor the health care system, government programs, and compliance with applicable laws. These oversight activities include, for example, inspections, medical device reporting and licensure.

16. Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose your PHI in response to a court or administrative order. We may also disclose your PHI 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.

17. Law Enforcement. We may release PHI if asked to do so by 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 at the clinic;
· 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.

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

19. National Security and Intelligence Activities. We may release PHI to authorize federal officials so they may provide protection to the President, or authorized persons or foreign heads of state or to conduct special investigations.

20. Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release your PHI to the correctional institution or law enforcement official. This release would be necessary (1) for the correctional institution to provide you with mental health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.


You have the following rights regarding your PHI:

1. Right to Inspect and Copy. You have the right to inspect and request a copy of your PHI, except as prohibited by law.

To inspect and/or request a copy of PHI that may be used to make decisions about you, you must submit your request in writing. If you request a copy of the information, we may charge a fee of 25 cents per page to offset the costs associated with the request.

We may deny your request to inspect and copy in certain circumstances. If you are denied access to certain PHI you may request the denial be reviewed. Another licensed healthcare professional chosen by the clinic 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.

2. Right to Amend. If you feel your PHI 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 or for the clinic. Your request for an amendment must be made in writing, stating the reason for the 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. Additionally, we may deny your request if you ask us to amend information that:
· Was not created by us, unless the person or entity creating the information is no longer available to make the amendment;
· Is not part of the PHI kept by or for the clinic;
· Is not part of the information which you would be permitted to inspect and copy;
· Is accurate and complete.

3. Right to an Accounting of Disclosures. You have the right to request for one free accounting every 12 months of the disclosures we made of your PHI. This request must be made in writing and state a time period, which may not be longer than six years, and may not include dates before April 14, 2003. We may charge for the costs for providing any additional list beyond the one free annually. 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.

4. Right to Request Restrictions. You have the right to request a restriction or limitation on the PHI we use or disclose about you for treatment, payment or healthcare operations. You also have the right to request a limit on the PHI we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had.

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.

You must make a request for restrictions in writing, telling 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.

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

You must make your request for confidential communications in writing. We will not ask you the reason for your request and will accommodate all reasonable requests; however you must specify how or where you wish to be contacted.

6. Right to Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

To obtain a paper copy of this notice, contact the clinic Privacy Officer, clinic manager or staff. You can also obtain a copy of this notice on our website at


We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for PHI 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 the clinic. The notice will contain on the first page, the effective date. In addition, each time you register at the clinic for treatment or healthcare services you may obtain a copy of the current notice in effect.


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


If you believe your privacy rights have been violated, you may file a written complaint with the clinic or with the Secretary of the Department of Health and Human Services.

To the clinic: Privacy Officer, Oasis Counseling Center Incorporated
4911 North Portland Avenue, Suite 111
Oklahoma City, OK 73112

To the Secretary of the Department of Health and Human Services: The U.S. Department of Health and Human Services

The complaint to the Secretary must be filed within 180 days of when the complainant knew or should have known the act or omission complained of occurred. The complaint must be in writing, name the entity that is the subject of the complaint, and describe the acts or omissions believed to be in violation of the standards.

You will not be penalized for filing a complaint.