Sam S. Dahr, M.D., PLLC dba Retina Center of Oklahoma
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.
If you have any questions about this Notice please contact the Privacy Officer at 405-713-4410.
This Notice of Privacy Practices describes how Dr. Dahr may use and disclose your protected health
information (PHI) to carry out treatment, payment or health care operations and for other purposes that
are permitted or required by law. It also describes your rights to access and control your PHI. PHI is
information about you, including demographic information, that may identify you and that relates to your
past, present or future physical or mental health or condition and related health care services.
Employees of Dr. Dahr are required to abide by the terms of this Notice to Privacy Practices. The
terms of this notice may change at any time. The new notice will be effective for all PHI that we
maintain at that time. Upon your request, we will provide you with any revised Notice to Privacy
Practices as necessary by calling the office and requesting that a copy be mailed to you or receiving one at the time of your next office visit.
Uses and Disclosures of PHI for Treatment, Payment, and Healthcare Operations:
Your PHI may be used and disclosed by your physician, our office staff and others outside of our office
that are involved in your care and treatment for the purpose of providing health care services to you.
Following are examples of the types of uses and disclosures of your PHI that the physician’s office is
permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office once you have provided consent.
TREATMENT: We will use and disclose your PHI to provide, coordinate, or manage your health care
and any related services. For example, the coordination of management of your health care with a third
party that has already obtained your permission t o have access to your PHI. We will disclose PHI to other physicians who may be treating you when we have the necessary per mission from you to disclose your PHI.
PAYMENT: Your PHI will be used, as needed to obtain payment for your health care services. For
example, certain activities that your health insurance plan may undertake before it approves or pays for
the health care services we recommend for you such as: making a determination of eligibility or coverage
for insurance benefits, reviewing services provided t o you for medical necessity, and undertaking
utilization review activities.
HEALTHCARE OPERATIONS: We may use or disclose, as needed, your PHI in order to support the
business activities of your physician’s practice. For example, activities include, but are not limited to,
quality assessment activities, employee review activities, training of medical students, licensing,
market ing and fundraising activities and conducting or arranging or other business activities.
For example, we may disclose your PHI to medical school students that see patients in our office. In
addition, we may use a signin sheet at the registration desk where you will be asked to sign your name
and indicate your physician. We may also call you by name in the wait ing room when your physician is
ready to see you. We may use or disclose your PHI, as necessary, to contact you to remind you of your
We will share your PHI with third party “business associates” that perform various activit ies, (e.g.,
billing, transcription services) for the practice. Whenever an arrangement bet ween our office and a
Business Associate involves the use of disclosure of your PHI, we will have a written contract that contains terms that will protect the privacy of your PHI.
We may use or disclose your PHI, as necessary to provide you with information about treatment
alternatives or other healthrelated benefits and services that may be of interest to you. We may also use
and disclose your PHI for other market ing activities as needed for sending a practice newsletter or
information about products or services that we believe may be beneficial to you.
Uses and Disclosures of PHI Based Upon Your Authorization
Other uses or disclosures of your PHI will be made only with your written authorization, unless other wise
permitted or required by law as described below. You may revoke this authorization, at any time, in
writing, except to the extent that your physician or the physician’s practice has taken an action in reliance
on the use or disclosure indicated in the authorization.
We may use or disclose your PHI in the following instances. You have the opportunity to agree or object
to the use or disclosure of all or part of your PHI. If you are not present or able to agree or object to the
use or disclosure of the PHI, then your physician may, using professional judgment, determine whet her
the disclosure is in your best interest. In this case, only the PHI that is relevant to your health care will be
Notification: Unless you object we may disclose to a member of your family, a relative, a close friend or
any other person, your identity and your PHI that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose information related to your location, general condition or death, if we determine that it is in your best interest based on our professional judgment. If we are unable to reach you or your family member or personal representative, then we may leave a message for them at the phone number that they have provided us, e.g., on an answer ing machine.
Emergencies: We may use or disclose your PHI in an emergency treatment situation. If this happens,
your physician shall try to obtain your consent as soon as reasonable practicable after the delivery of
treatment. If your physician or another physician in the practice is required by law to treat you and the
physician has attempted to obtain your consent but is unable to obtain your consent, he or she may still
use or disclose your PHI to treat you. We may use or disclose PHI to a public or private entity authorized
by law or by its charter to assist in disaster relief efforts, for the purpose of coordinating with such
Communication Barriers: We may use and disclose your PHI if your physician or another physician in
the practice attempts to obtain consent from you but is unable to do so due to substantial communication
barriers and the physician determines, using professional judgment, that you intend to consent to use or
disclosure under the circumstances.
Required by Law: We may use or disclose your PHI to the extent that the use or disclosure is required
by law. You will be notified, as required by law, of any such uses or disclosures.
Appointment Reminders: We may send you an appointment reminder or leave a message of such
appointment on your telephone answering machine, unless other wise instructed by you.
Public Health: We may disclose your PHI for the public health activities and purposes to a public health
authority that is permitted by law to collect or receive t he information. The disclosure will be made for
the purpose of controlling disease, injury or disability. We may also disclose your PHI, if directed by the
public health authority, to a foreign government agency that is collaborating with the authority.
Communicable Diseases: We may disclose your PHI, if authorized by law, to a person who may have
been exposed to a communicable disease or who may be at risk of contracting or spreading the condition.
Health Oversight: We may disclose PHI to a health oversight agency for activities authorized by law,
such as audits, investigations, and inspections. These agencies oversee the health care system,
government benefit programs, other government regulatory programs and civil rights laws.
Abuse or Neglect: We may disclose your PHI to a public health authority that is authorized by law to
receive reports of child abuse or neglect. We may disclose PHI if we believe you have been a victim of
abuse, neglect or domestic violence t o the government entity or agency authorized to receive such
information. This will be made within the requirements of applicable federal and state laws.
Food and Drug Administration: We may disclose your PHI to a person or company required by t he
FDA to report adverse events, product defects or problems, biological product deviations, track products;
to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance as
Legal Proceedings: We may disclose PHI in the course of any judicial or administrative proceeding, in
response to an order of a court or administrative tribunal (to the extent such disclosure is expressly
authorized), in certain conditions in response t o a subpoena, discover y request or other legal processes.
Law Enforcement: We may also disclose PHI, as long as applicable legal requirements are met, for law
enforcement purposes: (1) legal processes required by law, (2) limited information requests for
identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion t hat death has
occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of the
practice, and (6) medical emergency (not on t he Practice’s premises) when it is likely that a crime has
Coroners, Funeral Directors, and Organ Donation: We may disclose PHI to a coroner or medical
examiner and funeral direct or for identification purposes, determining cause of death or for them to
perform other duties authorized by law. PHI may be used for cadaveric or gan, eye or tissue donation
Research: We may disclose your PHI to researchers when their research has been approved by an
institutional review board that has reviewed t he research proposal and established protocols to ensure the privacy or your PHI.
Workers’ Compensation: Your PHI may be disclosed by use as authorized to comply with the workers’
compensation laws and other similar legally established programs.
Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by
the Secretary of the Department of Health and Human Services to investigate or deter mine our
compliance with the requirements of Section 164.500 et. seq.
You have the right to inspect and copy your protected health information that is contained in a designated
record set for as long as we maintain the PHI. Under federal law, however, you may not inspect or copy
the following records; psychotherapy notes; information compiled in a reasonable anticipation of, or use
in, a civil, criminal, or administrative action or proceeding, and PHI that is subject to law that prohibits
access to PHI. Depending on the circumstances, a decision to deny access may be reviewable. In some
circumstances, you may have a right to have t his decision reviewed. Please contact our Privacy Contact if you have any question about access to your medical record.
You have the right to request a restriction of your PHI. You may ask us not to use or disclose any part
of your PHI for the purposes of treatment, payment and healthcare operations. You may request your
PHI not be disclosed to family members or friends who may be involved in your care or for notification
purposes as described in the Notice of Privacy Practices. Your request must state specific restrictions
request ed. Your physician is not required to agree wit h the requested restriction. If your physician does
agree to the requested restriction, we may not use or disclose your PHI in violation of that restriction
unless it is needed to provide emergency treatment or is not in the best interest of the patient. With this in mind, please discuss any restrict ion you wish to request with your physician. He will document the
You have the right to request to receive confidential communications from us by alternative means or at
an alternative location. We will accommodate reasonable requests. We will ask how payment will be
handled or specification of an alternative address or other method of contact. Please request in writing.
You may have the right to request an amendment of your protected health information. Our office
requires this to be in writing. This information must be a part of your designated record. We may deny
your request however, you may file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you a copy of such. All protected health information request for ms will
be kept in the back of the patient record.
You have the right to receive an account ing of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures ot her than treatment, payment and operations as described in this Notice of Privacy Practices.
The right to receive this information is subject to certain except ions, restrictions or limitations.
You have the right to obtain a paper copy of this notice from us, even after electronic notification.
You may complain to this office or to the Secretary of Health and Human Services if you believe your
privacy rights have been violated by us. You may file a complaint by notifying the privacy contact at:
Sam S. Dahr, M.D., PLLC
3366 NW Expressway
Oklahoma City, Oklahoma 73116
This must be in writing. We will not retaliate against you filing a complaint.
This notice was published and becomes effective on August 14, 2006. We reserve the right to change this form. This entity reserves the right to change its practices.
FOR MORE FROM THE FEDERAL GOVERNMENT SEE http://www.hhs.gov/ocr/hipaa/