Notice of Privacy Practices Acknowledgement

Acknowledgement of Privacy Practices

Please review our Notice of Privacy Practices and sign below to acknowledge that you have been given a copy of or an opportunity to read the practice’s Notice of Privacy Practices.

NOTICE OF PRIVACY PRACTICES

Starbuck Medical LLC
Effective Date: 01/1/2022

Important Notice About Your Medical Information

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.

If you have any questions about this notice, please contact our privacy officer:

Crystal Starbuck
8341 Wolf Lake Drive
Piedmont, OK 73078
United States
(405) 633-3996

Summary of Rights and Obligations Concerning Health Information

Starbuck Medical LLC is committed to preserving the privacy and confidentiality of your health information, as required by law. We are required by law to provide you this notice describing:

  • Our legal duties

  • Your rights

  • Our privacy practices related to your health information

Each time you visit us, we make a record of your visit. Typically, this record contains:

  • Your symptoms

  • Examination and test results

  • Our assessment of your condition

  • A record of your treatment interventions

  • A plan for future care or treatment

We will only use or disclose this information in limited circumstances.

How We May Use and Disclose Your Health Information

We may use and disclose your health information to:

  • Plan your care and treatment

  • Provide treatment by us or others

  • Communicate with other providers

  • Receive payment from you, your health plan, or your insurer

  • Make quality assessments and improve care (health care operations)

  • Make you aware of services and treatments of interest

  • Comply with laws requiring disclosure

We may also use or disclose your information when you authorize us to do so.

Your Rights Regarding Your Health Information

You have the right to:

  • Ensure the accuracy of your health record

  • Request confidential communications

  • Request limits on the use and disclosure of your health information

  • Request an accounting of certain uses and disclosures

Our Responsibilities

We are required to:

  • Maintain the privacy of your health information

  • Provide you with this Notice of Privacy Practices

  • Abide by the terms of this notice

  • Notify you if we are unable to agree to a requested restriction

  • Accommodate reasonable requests for alternative communications

Changes to This Notice

We reserve the right to change our practices and apply the new provisions to all health information we maintain. If there is a material change, we will provide you a revised notice as required by law.

Detailed Explanations of Permitted Uses and Disclosures

Treatment

We may use and disclose your protected health information to provide, coordinate, and manage your care, including consulting with other providers or referring you to specialists.

Payment

We may use and disclose your health information for billing and payment purposes, such as:

  • Verifying insurance benefits

  • Billing your insurer

  • Sending bills to you or family members

  • Working with collection agencies or courts if payment is overdue

Health Care Operations

We may use and disclose your health information to:

  • Assess care and outcomes

  • Improve quality and effectiveness

  • Conduct cost-management and planning

Students

Students or interns may observe or participate in your care. You have the right to refuse student involvement.

Business Associates

We may share health information with third-party contractors (e.g., billing services, consultants) who must protect your information.

Appointment Reminders

We may contact you to remind you of appointments. You can request alternative communication methods.

Treatment Options and Health-Related Benefits

We may inform you of:

  • Alternative treatments

  • Health-related benefits and services

Release to Family and Friends

We may disclose health information to individuals involved in your care, unless you object.

Newsletters and Other Communications

We may contact you with newsletters or other information, subject to applicable laws.

Disaster Relief

We may disclose your health information to disaster relief organizations.

Marketing

We will not use your health information for marketing without written authorization, except in limited cases such as nominal promotional gifts or face-to-face discussions.

Fundraising

We may use certain information to contact you about fundraising. You may opt out at any time.

Public Health Activities

We may disclose information for public health purposes, such as:

  • Reporting disease, injury, or births and deaths

  • Reporting child abuse or neglect

  • Notifying persons exposed to disease

  • Reporting to authorities about victims of abuse

FDA and Regulatory Agencies

We may disclose information about adverse events to regulatory agencies.

Research

We may share your information for research if permitted by law or approved by a review board.

Workers’ Compensation

We may disclose information to comply with workers’ compensation laws.

Law Enforcement

We may release information:

  • In response to legal processes

  • To locate a suspect or witness

  • About crime victims

  • To report a death or crime

  • To authorized officials for security purposes

De-identified Information

We may create and use de-identified information that does not identify you.

Personal Representative

We will treat your personal representative as you regarding disclosures.

HLTV-III Test

Results will not be disclosed without your consent unless required by law.

Limited Data Set

We may provide limited data sets for research or public health if safeguards are in place.

Authorization for Other Uses of Medical Information

Other uses not described in this notice require your written authorization. You may revoke authorization at any time in writing, except where action has already been taken.

Your Health Information Rights

Right to Obtain a Paper Copy of This Notice
You have the right to a paper copy of this notice at any time.

Right to Inspect and Copy
You may inspect and copy your health records by submitting a written request. We may charge a reasonable fee.

Right to Amend
You may request amendments to your health information in writing, with a reason for the request.

Right to an Accounting of Disclosures
You may request an accounting of disclosures by submitting a written request. The first request in a 12-month period is free.

Right to Request Restrictions
You can request restrictions on how we use or disclose your information. We are not required to agree, except as required by law when you pay out-of-pocket.

Right to Request Confidential Communications
You can request communication through specific means or locations.

Right to Receive Notice of a Breach
We will notify you of any breaches of unsecured protected health information.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with:

  • Starbuck Medical (contact our privacy officer)

  • Secretary of the U.S. Department of Health and Human Services

Complaints must be in writing. You will not be penalized for filing a complaint.

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