Wynter Kipgen, MD and Kimberly Hummer, MD

Call Us:  405-608-4520

A. Our Pledge Regarding Your Privacy

This notice describes how we may use and disclose your protected health information for treatment, payment or healthcare operations and for other purposes permitted or required by law. It describes your rights to access and control your protected health information. Protected health information is information about you, including vital 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. We are committed to maintaining the privacy of your protected health information.


The law requires us to do the following:

Keep your health information private

Provide you with our policy of privacy practices

Follow the guidelines of the notice that is currently in use


We may revise or amend the terms of this notice, at any time. The new notice will apply to all protected health information that our practice has created or maintained in the past, and for any protected health information that we may create or maintain in the future. We will post our current notice in our office in a visible location at all times and upon your request, we will provide you with a revised notice.  


B. If you have questions about this notice, please contact our privacy office. The name and contact information of our privacy office can be obtained from our receptionist.


C. We may use and disclose your protected health information in the following ways:


1. Treatment. We will use your health information to provide you with medical treatment or services. This includes the coordination of care with a third party. For example, we may ask you to have laboratory tests, and we may use the results to help us reach a diagnosis. We might use your protected health information to write or order a prescription for you. Many of the people who work for our practice – including, but not limited to, our doctors and nurses – may use or disclose your protected health information to treat you or to assist others in your treatment. We may disclose your protected health information to others who may assist in your care, such as your spouse, children or parents. We may also disclose your protected health information to other health care providers for purposes related to your treatment.


2. Payment. Your protected health information will be used, as needed, to obtain payment for your health care services. This may include activities that your health insurance plan may undertake before it approves or pays for the health care services. This may include making determination of eligibility or coverage for insurance benefits, reviewing services for medical necessity, and utilization review activities.


3. Health Care Operations. We may use or disclose, as needed, your protected health information to support the business activities of our practice. These activities may include quality assessment activities, employee reviews, licensing, and conducting or arranging other business activities. For example, we may use a sign-in sheet at the registration desk. We may also call you by name in the waiting room. We will share your protected health information with third party “business associates” that perform various activities (e.g. billing, transcription services) for the practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that protects your privacy.


4. Appointment Reminders. We may use and disclose your protected health information to remind you of an appointment.


5. Treatment Options. We may use and disclose your protected health information to inform you of potential treatment options or alternatives.


6. Health-Related Benefits and Services. We may use and disclose your protected health information to inform you of health-related benefits or services that may be of interest to you.


7. Release of Information to Family/Friends. Unless you object, we may disclose to a member of your family, a relative, a close friend or any other persons you identify, your protected health information 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 such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death.  


8. Disclosures Required By Law. We will use and disclose your protected health information to the extent necessary when required by federal, state or local law.


D. Use and disclosure of your protected health information in certain special circumstances.


1. Public Health Risks. We may disclose your protected health information to public health authorities that are authorized by law to collect information for the purpose of:

Preventing or controlling disease, injury or disability

Reporting births and deathsReporting child abuse or neglect

Reporting reactions to medications or problems with products

Notifying people of product recalls

Notifying a person who may have been exposed to a disease or may be at risk to contract or spread a disease or condition

Notifying appropriate government authorities regarding potential abuse or neglect of an adult patient (including domestic violence). We will only disclose this information if the patient agrees or if we are required or authorized by law.

Notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance.


2. Health Oversight Activities. We may disclose your protected health information to a health oversight agency for activities authorized by law. Oversight activities can include, for example, audits, investigation, inspections and licensure. These activities are necessary for the government to monitor the healthcare system, government programs, and compliance with civil rights laws.


3. Lawsuits and Disputes. If you are involved in a lawsuit or dispute, we may disclose your protected health information in response to a court or administrative order. We may also disclose your protected health information in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if efforts have been made to inform you of the request or to obtain an order protecting the information requested.


4. Law Enforcement. We may release protected health information if asked to do so by a law enforcement official:

In response to a warrant, summons, court order, subpoena or similar legal process;

To identify/locate a suspect, material witness, fugitive or missing person;

About a crime victim in certain situations, if we are unable to obtain the person’s agreement;

About a death we believe may have resulted from a crime;

About criminal conduct involving our practice; and

In emergency circumstances to report a crime; or details of the crime including location, victim(s), or the description, identity or location of the person who committed the crime.


5. Medical Examiners/Funeral Directors. We may release protected health information to a medical examiner/coroner to identify a deceased individual or to identify the cause of death. We also may release information for funeral directors to perform their jobs.


6. Organ and Tissue Donation. If you are an organ donor, we may release your protected health information to organizations that handle organ, eye or tissue procurement or transplantation, including organ donation banks, as necessary to facilitate organ or tissue donation and transplantation.


7. Research. We may disclose your protected health information to researchers when the research has been approved by an institutional review board that has reviewed the proposal and established protocols to ensure the privacy of your protected health information. Otherwise, we will ask for a written authorization from you.


8. Serious Threats to Health or Safety. We may use and disclose your protected health information to reduce or 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.


9. Military. If you are a member of the armed forces, we may release protected health information about you as required by military command authorities. We may also release health information about you to a foreign military authority.


10. National Security. We may release health information about you to federal offices for intelligence, counterintelligence, and other national security activities authorized by law.


11. Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release protected health 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 your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.


12. Workers’ Compensation. We may release protected health information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness. Release of such information is controlled by state and/or federal law.


E. Your rights regarding your protected health information


1. Confidential Communications. You have the right to ask that we communicate with you about medical matters in a certain way or at a certain location. For instance, you can ask that we only contact you at home or by mail. To request confidential communications, you must make your request in writing to our privacy officer. We will not ask you for a reason for your request. We will honor all reasonable requests. Your request must specify how or where you wish to be contacted.


2. Requesting Restrictions. You have the right to request a restriction or limitation on the protected health information we use of disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or in 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 your medical history. 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 our privacy officer. In your request, you must tell us:

(a) the information you wish restricted;

(b) whether you are requesting to limit our use, disclosure or both; and

(c) to whom you want the limits to apply. 


3. Inspection and Copies. You have the right to inspect and copy protected health information that may be used to make decisions about your care. Usually, this includes patient medical records and billing records, but not psychotherapy notes. To inspect and/or copy your protected health information, you must submit your request in writing to our privacy officer. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other expenses associated with your request. We may deny your request to inspect and/or copy in certain limited circumstances. If you are denied access to health information, you may request a review of the denial. Another licensed health care professional chosen by us will review your request and our denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.


4. Right to Amend. If you believe that protected health information we have about you is incorrect or incomplete, you may ask us to change the information. You have the right to request an amendment for as long as the information is kept by or for our practice. Your request for amendment must be made in writing and submitted to our privacy officer. You must provide us with a reason that supports your 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: (a) Was not created by us, unless the person or entity that created the information is no longer available to make the amendment: (b) Is not part of the protected health information kept by or for the practice; (c) Not part of the protected health information which you would be permitted to inspect and copy; or (d) Is accurate and complete.


5. Accounting of Disclosures. You have the right to request an “accounting of disclosures”. This is a list of the disclosures we made of your protected health information. To request this list, you must submit your request in writing to our privacy officer. Your request must state a time period that may not be longer than six years and may not include dates before April 14, 2003. The first list you request within a 12-month period is free of charge. For additional lists within the same 12-month period, we may charge you for the cost of providing the list. You will be notified of the cost and you may withdraw or modify your request before you incur any costs.


6. Right to a Paper Copy of This Notice. You are entitled to receive a paper copy of this notice at any time. To obtain a copy, contact our privacy officer. 7. Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with our practice by asking for our Privacy Officer, or with the Office for Civil Rights, U.S. Department of Health & Human Services, 1301 Young Street, Suite 1169, Dallas, TX 75202. All complaints must be in writing. You will not be penalized for filing a complaint.


8. Right to Provide an Authorization for Other Uses and Disclosures. Other uses and disclosures or protected health 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 your protected health information, you may revoke that permission, in writing, at any time. If revoked, we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures that have already been made with your permission, and that we are required to retain our records of the care that we provided to you.


Again, if you have any questions regarding this notice or our health information privacy policies, please contact our privacy officer.