ABOUT THIS NOTICE
Amherst Audiological Services is committed to protecting your health information. This Notice of Privacy Practices (“Notice”) is provided pursuant to the Health Insurance Portability and Accountability Act of 1996 (“HIPPA”) as revised in the 2013 HIPPA Omnibus Rule. This Notice describes how we may use and disclose your protected health information to carry out treatment, payment for hearing health care operations and for other purposes that are permitted or required by law. This Notice also describes your rights and our duties with respect to your protected health information.
Your Information. Your Rights. Our Responsibilities.
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.
You have the right to: 1) Get a copy of your paper or electronic medical record 2) Correct your paper or electronic medical record 3) Request confidential communication 4) Ask us to limit the information we share 5) Get a list of those with whom we’ve shared your information 6) Get a copy of this privacy notice 7) Choose someone to act for you 8) File a complaint if you believe your privacy rights have been violated
You have some choices in the way that we use and share information as we: 1) Tell family and friends about your condition 2) Provide disaster relief 3) Market our services and sell your information 4) Raise funds
OUR USES AND DISCLOSURES:
We may use and share your information as we: 1) Treat you 2) Run our organization 3) Bill for your services 4) Help with public health and safety issues 5) Do research 6) Comply with the law 7) Respond to organ and tissue donation requests 8) Work with a medical examiner or funeral director 9) Marketing
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you. You have the right to:
Get an electronic or paper copy of your medical record: You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your medical record: You can ask us to correct health information about you that you think is incorrect or incomplete. We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications: You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests.
Ask us to limit what we use or share: You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
Get a list of those with whom we’ve shared information: You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, health care operations, and certain other disclosures, such as any you asked us to make. We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Right to get notice of a breach. You have the right to be notified upon a breach of any of your unsecured protected health information.
Get a copy of this privacy notice: You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you: If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated: You can complain if you feel we have violated your rights by contacting our privacy officer listed at the end of this document. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to: 1) Share information with your family, close friends, or others involved in your care 2) Share information in a disaster relief situation 3) Raise funds
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In the following cases we never share your information unless you give us written permission:
1) Marketing purposes 2) Sale of your information
Our Uses and Disclosures:
The following describes the ways we may use and disclose health information that identifies you (“Protected Health Information”) or (“PHI”). PHI is information about you that may identify you and that relates to your past, present or future physical or mental health/condition and related hearing health care services. Except for the purposes described below, we will use and disclose PHI only with your written permission. You may revoke such permission at any time by writing to our practice Privacy Officer.
For Treatment: We may use and disclose PHI for your treatment and to provide you with treatment-related health care services. For example, we may disclose PHI to doctors, nurses, technicians, or other personnel, including people outside our office, who are involved in your medical care and need the information to provide you with medical care.
For Payment: We may use and disclose PHI so that we or others may bill and receive payment from you, an insurance company or a third party for the treatment and services you received. For example, we may give your health plan information about you so that they will pay for your treatment.
For Health Care Operations: We may use and disclose PHI for health care operations purposes. These uses and disclosures are necessary to make sure that all of our patients receive quality care and to operate and manage our office. For example, we may use and disclose information to make sure the hearing health care you receive is of the highest quality. We also may share information with other entities that have a relationship with you (for example, your health plan) for their health care operation activities.
Appointment Reminders, Treatment Alternatives and Health Related Benefits and Services: We may use and disclose PHI to contact you to remind you that you have an appointment with us. We also may use and disclose PHI to tell you about hearing treatment alternatives or hearing health-related benefits and services that may be of interest to you.
Other Disclosures: We may share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help With Public Health and Safety Issues: We can share health information about you for certain situations such as: 1)Preventing disease 2) Helping with product recalls 3) Reporting adverse reactions to medications 4) Reporting suspected abuse, neglect, or domestic violence 5) Preventing or reducing a serious threat to anyone’s health or safety
Do Research: We can use or share your information for health research.
Comply With the Law: We will share information about you if state or federal laws require it, including with the Department of Health and Human Services, if it wants to see that we’re complying with federal privacy law.
Respond to Organ and Tissue Donation Requests: We can share health information about you with organ procurement organizations.
Work With a Medical Examiner or Funeral Director: We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address Workers’ Compensation, Law Enforcement, and Other Government Requests: We can use or share health information about you: 1) For workers’ compensation claims 2) For law enforcement purposes or with a law enforcement official 3) With health oversight agencies for activities authorized by law 4) For special government functions such as military, national security, and presidential protective services
Respond to Lawsuits and Legal Actions: We can share health information about you in response to a court or administrative order, or in response to a subpoena.
YOUR WRITTEN AUTHORIZATION IS REQUIRED FOR OTHER USES AND DISCLOSURES
Other uses and disclosures of PHI not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you do give us an authorization, you may revoke it at any time by submitting a written revocation to our Privacy Officer and we will no longer disclose PHI under the authorization. But disclosure that we made in reliance on your authorization before you revoked it will not be affected by the revocation.
We are required by law to:
- Maintain the privacy and security of protected health information
- Give you this notice of our legal duties and privacy practices regarding health information about you
- Follow the terms of our notice that is currently in effect
Changes to the Terms of this Notice:
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our website.
Other Instructions for Notice
- Effective 10/15/2013
- Emily Miller, Privacy Officer. 716-838-5360. firstname.lastname@example.org