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.
I. Our Privacy Pledge and Duties.
While we have and always will respect your
privacy, a new federal law now requires us to maintain the privacy
of hearing health information and other medical information
(including examination, treatment and billing records) about you
and to provide you with this Notice of our legal duties and
privacy practices with respect to such health information.
We must abide by the terms of this Notice while
it is in effect. However, we reserve the right to change terms of
our privacy notices. If we change the terms of the Notice, we will
notify you during your next visit or by mail.
II. Permissible Uses and Disclosures Without
In certain situations (described in Section III below), we must
obtain your written authorization in order to use and/or disclose
your health information. However, here are some examples of how we
might use or disclose your health information (other than highly
confidential information) without first obtaining your written
A. Uses and Disclosures for Treatment, Payment or Health
- Treatment. Your hearing health care professional
or staff member may use and disclose your health
information to diagnose, assess and treat your health
- Payment. Our insurance and billing staff may
disclose your health information to an insurance carrier,
HMO, PPO, your employer, or other party that arranges or
pays the cost of some or all of your health care, or to
verify that such parties will pay for your health care.
- Health Care Operations. Your hearing health care
professional and members of the staff may use or disclose
your health information for quality control purposes or
for other administrative purposes to efficiently and
effectively run his/her practice.
- Appointment Reminders. Your hearing health care
professional and members of the staff may need to use your
name, address, phone number, and other health information
to contact you to provide appointment reminders,
information about treatment alternatives, or other health
related information that may be of interest to you. If you
are not at home to receive an appointment reminder, a
message will be left on your answering machine or at
another location that you reasonably request.
- Other Providers. Your hearing health care
professional and members of the staff may use or disclose
your health information to another health care provider,
product manufacturer, or a hospital if it is necessary to
refer you to them or they are otherwise involved in your
care when such information is required for them to treat
you, receive payment for services they render to you, or
conduct certain health care operations, such as quality
assessment and improvement activities, reviewing the
quality and competence of health care professionals, or
for health care fraud and abuse detection or compliance.
B. Disclosures to Relatives, Close Friends
and Other Caregivers. Your hearing health care professional
and members of the staff may use or disclose your health
information to one of your family members, other relative, a close
personal friend or any other person identified by you when you are
present for, or otherwise available prior to, the disclosure. If
you object to such uses or disclosures, please notify your hearing
health care professional.
If you are not present, you are incapacitated
or in an emergency circumstance, we may exercise our professional
judgment to determine whether a disclosure is in your best
interests. We may also disclose your health information to notify
such persons of your location or general condition.
C. Other Permitted Uses and Disclosures
Without Your Authorization. Under federal law, we are also
permitted or required to use or disclose your health information
without your authorization in these following circumstances:
- Public Health Activities. We may disclose your
health information for certain public health activities
such as (i) reporting health information to public health
authorities for the purpose of preventing or controlling
disease, injury or disability; (ii) reporting child abuse
and neglect to authorities authorized by law to receive
such reports; (iii) reporting information about products
or services under the jurisdiction of the U.S. Food &
Drug Administration; (iv) alerting a person who may have
been exposed to a communicable disease or who may
otherwise be at risk of contracting or spreading a disease
or condition; and (v) reporting information to your
employer as required under laws addressing work-related
illnesses and injuries or workplace medical surveillance.
- Victim of Abuse, Neglect or Domestic Violence. If
we reasonably believe you are a victim of abuse, neglect
or domestic violence, we may disclose health information
to a governmental authority, including a social service or
protective services agency, authorized by law to receive
reports of such abuse, neglect or domestic violence.
- Health Oversight Activities. We may disclose your
health information to a health oversight agency that
oversees the health care system and is charged with
responsibility for ensuring compliance with the rules of
government health care programs such as Medicare or
- Judicial and Administrative Proceedings. We may
disclose your health information in the course of a
judicial or administrative proceeding in response to a
legal order or other lawful process.
- Law Enforcement Officials. We may disclose your
health information to the police or other law enforcement
officials as required or permitted by law or in compliance
with a court order or a grand jury or administrative
- Decedents. We may disclose your health information
to a coroner or medical examiner as authorized by law.
- Organ and Tissue Procurement. We may disclose your
health information to organizations that facilitate organ,
eye or tissue procurement, banking or transplantation.
- Research. We may use or disclose your health
information if an Institutional Review Board approves a
waiver of authorization for use or disclosure.
- Health or Safety. We may use or disclose your
health information to prevent or lessen a serious and
imminent threat to a person’s or the public’s health
- Specialized Government Functions. We may use or
disclose your health information to units of the
government with special functions, such as the U.S.
military or the U.S. Department of State under certain
circumstances required by law.
- Workers’ Compensation. We may disclose your
health information as authorized by and to the extent
necessary to comply with laws relating to workers’
compensation or other similar programs.
- As Required by Law. We may use or disclose your
health information when required to do so by any other law
not already referred to in the preceding categories.
III. Uses and Disclosures Requiring Your
A. Uses or Disclosure With Your
Authorization. Other than the circumstances described above,
any other use or disclosure of your health information will only
be made with your written authorization. Additionally, you have
the right to refuse to give us authorization to use or disclose
your health information for purposes other than those described
above. If you do not give us authorization, it will not affect the
treatment we provide to you or the methods we use to obtain
reimbursement for your care.
B. Your Right to Revoke Your Authorization.
You may revoke your authorization to us at any time; however, your
revocation must be in writing. There are two circumstances under
which we will not be able to honor your revocation request:
- If we have taken an action in reliance upon such
authorization before we receive your request to revoke
- If you were required to give your authorization as a
condition of obtaining insurance, the insurance company
may have a right to your health information if they
decide to contest any of your claims. If you wish to
revoke your authorization, please write to us at the
address given in Section VII below.
C. Marketing. We must also obtain your
written authorization prior to using your health information to
make you aware of products or services that you may have an
interest in purchasing from time to time. We can, however, provide
you with marketing materials in a face-to-face encounter without
obtaining your authorization. We are also permitted to give you a
promotional gift of nominal value, if we so choose, without first
obtaining your authorization. Additionally, we may communicate
with you about products or services relating to your treatment,
case management or care coordination, or alternative treatments,
therapies, providers or care settings.
D. Uses and Disclosures of Your Highly
Confidential Information. In addition, federal and state law
requires special privacy protections for certain highly
confidential information about you. In order for us to disclose
your highly confidential information for a purpose other than
permitted by law, we must obtain your written authorization.
E. Right to Refuse Authorization. You
have the right to refuse to give us an authorization to use or
disclose your health information or otherwise contact you for
purposes other than those set forth in Section II above. If you do
not give us authorization, it will not affect the treatment we
provide to you or the methods we use to obtain reimbursement for
IV. Your Individual Rights.
A. Your Right to Receive Confidential
Communication Regarding Your Health Information. We normally
provide information about your health in person, at the time you
receive hearing care services from us. We may also mail you
information regarding your health or about the status of your
account. We will do our best to accommodate any reasonable request
if you would like to receive information about your health or the
services that we provide by an alternative means of communication
or at an alternative location. To help us respond to your needs,
please make any requests in writing.
B. Right to Request Additional Restrictions.
You may request restrictions on our use and disclosure of your
health information (1) for treatment, payment and health care
operations, (2) to individuals (such as a family member, other
relative, close personal friend or any other person identified by
you) involved with your care or with payment related to your care,
or (3) to notify or assist in the notification of such individuals
regarding your general location and general condition. All
requests for such restrictions must be made in writing. While we
consider all requests for additional restrictions carefully, we
are not required to agree to a requested restriction.
C. Your Right to Inspect and Copy Your
Health Information. You may request access to your health
information maintained by us in order to inspect and/or copy your
health information. We require your request to inspect an/or copy
your health information to be in writing. If you request copies,
we will charge you .82 per page. We will also charge you for our
postage costs, if you request that we mail the copies to you.
D. Your Right to Amend Your Health
Information. You have the right to request that we amend your
health information maintained by us. We require your request to
amend your records to be in writing and for you to give us a
reason to support the change you are requesting us to make.
E. Your Right to Receive an Accounting of
the Disclosures We Have Made of Your Records. You have the
right to request that we give you an accounting of the disclosures
we have made of your health information for the last six years
before the date of your request, provided such request does not
apply to disclosures that occurred prior to April 14, 2003. The
accounting will include all disclosures except those disclosures:
- required to carry out treatment, payment and health care
- to you.
- that are incident to a permitted use or disclosure.
- made pursuant to an authorization.
- required to maintain a directory of the individuals in our
facility or to individuals involved with your care.
- required for national security or intelligence purposes.
- to correctional institutions or law enforcement officers.
- made as part of a limited data set.
- made prior to April 14, 2003.
If you request an accounting more than once
during a twelve (12) month period, we will charge .82 per page of
the accounting statement.
Information that we use or disclose may be
subject to re-disclosure by the person to whom we provide the
information and may no longer be protected by federal law.
VII. Your Right to Obtain Further Information; Complaints.
If you desire further information about your
privacy rights, are concerned that we have violated your privacy
rights or disagree with a decision that we made about providing
you access to your health information, please contact us. You may
also file written complaints with the Director, Office for Civil
Rights of the U.S. Department of Health and Human Services. Upon
request, we will provide you with the address for the Director. We
respect your right to file a complaint and will not take any
action against you if you file a complaint. While you may make an
oral complaint or request information at any time, written
comments should be addressed to:
DECATUR HEARING AID SERVICE
917 N. INDIAN CREEK DR.
PO BOX 91
CLARKSTON, GA. 30021
VIII. Your Right to Receive a Paper Copy of this Notice.
Upon written request, you may obtain a paper copy of this Notice,
even if you have agreed to receive this Notice electronically.
IX. Effective Date. This Notice is effective as of April