As Required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and as revised in the 2013 HIPAA Omnibus Rule
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU (AS A PATIENT OF THIS PRACTICE) MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO YOUR PROTECTED HEALTH INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY
A. OUR COMMITMENT TO YOUR PRIVACY
Our practice is dedicated to maintaining the privacy of your protected health information. Protected Health Information (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 audiological/healthcare services. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your PHI. By federal and state law, we must follow the terms of this notice of privacy practices while it is in effect.
We realize that these laws are complicated, but we must provide you with the following important information:
- How we may use and disclose your PHI to carry out treatment, payment, or audiological/health care operations and for other purposes that are permitted or required by law
- Your privacy rights with respect to your PHI
- Our obligations concerning the use and disclosure of your PHI
The terms of this notice apply to all records containing your PHI that are created or retained by our practice.
B. IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:
101 W. Randol Mill Rd., #100
Arlington, TX 76011
C. WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION (PHI) IN THE FOLLOWING WAYS
The following categories describe the different ways in which we may use and disclose your PHI. These examples are not meant to be exhaustive, but to illustrate the types of uses and disclosures that may be made.
- Treatment. We may use your PHI to provide, coordinate, or manage your audiological treatment and related services. For example, we may ask you to undergo a hearing test, and we may use the results to help us reach a diagnosis. We might use your PHI in order to recommend certain hearing aids for you, or we might disclose your PHI to a hearing aid laboratory when we order a hearing aid for you. Many of the people who work for our practice – including , but not limited to, our audiologists and office staff – may use or disclose your PHI in order to treat you or to assist others in your treatment. Additionally, we may disclose your PHI to others who may assist in your care, such as your spouse, children, or parents. Finally, we may also disclose your PHI to other third party providers involved in your audiological/heath care, such as your physician or other audiological/health care provider to whom you have been referred, for purposes related to your diagnosis and treatment.
- Payment. We may use and disclose your PHI in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. This may include certain activities that your insurer may undertake before it approves or pays for the audiological/health care services we recommend for you, such as determining eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and utilization review activities. We may also disclose your PHI to obtain payment from third parties that may be responsible for such costs, such as family members, a government program, or other third party payers. Also, we may use your PHI to bill you directly for services and items. We may disclose your PHI to other health care providers and entities to assist in their billing and collection efforts.
- Health Care Operations. Our practice may use and disclose your PHI to operate our business. As examples of the ways in which we may use and disclose your information for our operations, our practice may use your PHI to evaluate the quality of care you received from us and to evaluate the performance of our staff, or to conduct cost-‐management and business planning activities. We may also disclose information to audiologists, physicians, nurses, technicians, audiology students, and other personnel for educational and learning purposes and to assist in their health care operations.
- Appointment Reminders. Our practice may use and disclose your PHI to contact you and remind you of an appointment.
- Treatment Communications. We may provide treatment communications concerning treatment alternatives or other health related products or services. For communications for which we or a business associate may receive financial remuneration in exchange for making the communication, we must obtain your written authorization unless the communication is made face-‐to-‐face and/or involving promotional gifts of nominal value. If you do not wish to receive these communications, please submit a written request to our Privacy Office, Melissa Danchak, Kos/Danchak Audiology & Hearing Aids, 101 W. Randol Mill Rd., Ste. 100, Arlington, TX 76011.
- Fundraising Activities. We may use or disclose your demographic information and dates of services provided to you, as necessary, in order to contact you for fundraising activities supported by Kos/Danchak Audiology & Hearing Aids. You have the right to opt out of receiving fundraising communications. If you do not want to receive these materials, please submit a written request to our Privacy Officer, Melissa Danchak,Kos/Danchak Audiology & Hearing Aids, 101 W. Randol Mill Rd., Ste. 100, Arlington, TX 76011.
- Release of Information to Others Involved in Your Healthcare Unless you object, we may disclose your PHI to a member of your family, a relative, a friend, or any other person you identify that is directly involved in your health care or who assists in taking care of you. For example, a grown child of an elderly adult or a caretaker of an elderly adult who may bring the patient to our office for evaluation and treatment may have access to the patient’s medical information. 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 upon our professional judgment. We may also use and disclose your PHI to notify such persons of your location, general condition, or death. We also may coordinate with disaster relief agencies to make this type of notification. We also may use professional judgment and our experience with common practice to make reasonable decisions about your best interests in allowing a person to act on your behalf to pick up your hearing devices, supplies, records, or other things that contain PHI about you.
- Disclosure Required by Law. Our practice will use and disclose your PHI to the extent that we are required to do so by federal, state, or local law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses and disclosures.
D. USE AND DISCLOSURE OF YOUR PHI IN CERTAIN SPECIALS CIRCUMSTANCES
The following categories describe unique scenarios in which we may use or disclose your PHI:
- Public Health Risks. We may disclose your PHI to public health authorities that are authorized by law to collect information for the purposes of:
• Maintaining vital records, such as births and deaths
• Reporting child abuse or neglect
• Preventing or controlling disease, injury, or disability
• Notifying a person regarding potential exposure to a communicable disease
• Notifying a person regarding potential risk for spreading or contracting a disease or condition
• Reporting to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products to enable product recalls, to make repairs or replacements, or to conduct post marketing surveillance, as required by law
• Notifying appropriate government agency(ies) and authority(ies) regarding potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information. The disclosure will be made consistent with the requirements of applicable federal and state laws
• Notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance
• When directed by the public health authority to disclose your PHI to a foreign governmental agency that is collaborating with the public health authority
- Business Associates. We may disclose your PHI to our business associates that perform function on our behalf or provide us with services if the information is necessary for such functions or services. To protect your PHI, however, we require the business associate to appropriately safeguard your information.
- Health Oversight Activities. Our practice may disclose your PHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.
- Lawsuits and Similar Legal Proceedings. We may use and disclose your PHI in the course of any judicial or administrative proceeding, in response to a court or administrative tribunal, to the extent such disclosure is expressly authorized, and in certain conditions in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party requested.
- Law Enforcement. We may release PHI if asked to do so by a law enforcement official:
• Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement
• Concerning a death we believe has resulted from criminal conduct
• Regarding criminal conduct at our offices
• In response to a warrant, summons, court order, subpoena, or similar legal process
• To identify/locate a suspect, material witness, fugitive or missing person
• In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity, or location of the perpetrator)
- Coroners, Funeral Directors, and Organ Donation. We may disclose your PHI to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose your PHI to a funeral director, as authorized by law, in order to permit the funeral director to carry out his/her duties. We may disclose such information in reasonable anticipation of death. PHI may be used and disclosed for cadaveric organ, eye, or tissue procurement or transplantation.
- Research. Our practice may use and disclose your PHI for research purposes in certain limited circumstances. We will obtain your written authorization to use your PHI for research purposes except when an Institutional Review Board or Privacy Board has determined that the waiver of your authorization satisfies the following: (i) the use or disclosure involves no more than a minimal risk to your privacy based on the following: (A) an adequate plan to protect the identifiers from improper use and disclosure; (B) an adequate plan to destroy the identifiers at the earliest opportunity consistent with the research (unless there is a health or research justification for retaining the identifiers or such retention is otherwise required by law); and
(C) adequate written assurances that the PHI will not be re-‐used or disclosed to any other person or entity (except as required by law) for authorized oversight of the research study, or for other research for which the use or disclosure would otherwise be permitted; (ii) the research could not practicably be conducted without the waiver; and (iii) the research could not practicable be conducted without access to and use of the PHI.
- Serious Threats to Health or Safety. We may use and disclose your PHI when necessary to reduce or prevent serious threat to your health and safety or the health and safety of another individual or the public, consistent with applicable federal and state laws. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.
- Military Activity and National Security. If you are involved with U.S. or foreign military, national security, or intelligence activities or if you are in law enforcement custody, we may disclose your PHI to authorized officials so they may carry out their legal duties under the law.
- Workers’ Compensation. Our practice may release your PHI as authorized for workers’ compensation or other similar programs that provide benefits for a work-‐related illness.
- For Data Breach Notification Purposes. We may use or disclose your PHI to provide legally required notices of unauthorized access to or disclosure of your health information.
- Required Uses and Disclosures. Under the law, we must make disclosures to you and when required by the Secretary of the U.S. Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 16.500 et. Seq.
SPECIAL PROTECTIONS FOR HIV, ALOCHOL, AND SUBSTANCE ABUSE, MENTAL HEATLH AND GENETIC INFORMATION
Certain federal and state laws may require privacy protections that restrict the use and disclosure of certain health information, including HIV-‐related information, alcohol and substance abuse information, mental health information, and genetic information. Some parts of this Notice may not apply to these types of information.
USES AND DISCLOSURE OF PHI BASED UPON YOUR WRITTEN AUTHORIZATION
The following uses and disclosures will be made only with your written authorization:
- Uses and disclosures of PHI for marketing purposes for which we or a business associate may receive remuneration; and
- Disclosures that constitute a sale of PHI.
Other uses and disclosures of your PHI not described in this Notice will be made only with your written authorization, unless otherwise permitted or required by law. You may revoke this authorization, at any time, in writing, except to the extent Kos/Danchak Audiology & Hearing Aids has taken an action in reliance on the use or disclosure indicated in the authorization. Additionally, if a use or disclosure of PHI described above in this Notice is prohibited or materially limited by other laws that apply to use, it is our intent to meet the requirements of the more stringent law.
YOUR RIGHTS REGARDING YOUR PHI
The following is a statement of your rights with respect to your PHI and a brief description of how you may exercise these rights.
- Right to be Notified if there is a Breach of Your PHI. You have the right to be notified upon a breach of any of your unsecured PHI.
- Right to Request Confidential Communications. You have the right to request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a type of confidential communication, you must make a written request to our Privacy Office, Melissa Danchak, Kos/Danchak Audiology & Hearing Aids, 101 W. Randol Mill Rd., Ste. 100, Arlington, TX 76011 specifying the requested method of contact, or the location where you wish to be contacted. Our practice will accommodate reasonable requests. You do not need to give a reason for your request.
- Right to Request Restrictions. You have the right to request a restriction in our use or disclosure of your PHI for treatment, payment, or health care operations. Additionally, you have the right to request that we restrict our disclosure of your PHI to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request, unless you are asking us to restrict the use and disclosure of your PHI to a health plan for payment or audiological//health care operation purposes and such information you wish to restrict pertains solely to a audiological/health care item or service for which you have paid us “out-‐of-‐pocket” in full. If we believe it is in your best interest to permit the use and disclosure of your PHI, your PHI will not be restricted. If we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your PHI, you must make your request in writing to our Privacy Officer, Melissa Danchak, Kos/Danchak Audiology & Hearing Aids, 101 W. Randol Mill Rd., Ste. 100, Arlington, TX 76011. Your request must describe in a clear and concise fashion:
- The information you wish restricted;
- Whether you are requesting to limit our practice’s use, disclosure, or both; and
- To whom you want the limits to apply.
- Right to Inspect and Copy. You have the right to inspect and obtain a copy of the PHI that is contained in your medical and billing records or any other records the Kos/Danchak Audiology & Hearing Aids uses for making decisions about you. Under federal law, you may not inspect or copy the following records: psychotherapy notes; information compiled in 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. You must submit your request in writing to our Privacy Office, Melissa Danchak, Kos/Danchak Audiology & Hearing Aids, 101 W. Randol Mill Rd., Ste. 100, Arlington, TX 76011, in order to inspect and/or obtain a copy of your PHI. Our practice may charge a reasonable fee for the costs of copying, mailing, labor, and supplies associated with your request. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed health care professional chosen by us will conduct reviews.
- Right to Request Amendment. You may request an amendment of your PHI contained in your medical and billing records and any other records that Kos/Danchak Audiology & Hearing Aids uses for making decisions about you, for as long as we maintain the PHI. Your request for an amendment must be made in writing to our Privacy Office, Melissa Danchak,
Kos/Danchak Audiology & Hearing Aids, 101 W. Randol Mill Rd., Ste. 100, Arlington, TX 76011. You must provide us with a reason that supports your request for amendment. Our practice will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the PHI kept by and for the practice; (c) not part of the PHI which you would be permitted to inspect and copy; or (d) not created by our practice, unless the individual or entity that created the information is not available to amend the information. If we deny your request for an amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.
- Right to an Accounting of Disclosures. You have the right to receive an accounting of certain disclosures we have made, if any, of your PHI. This right applies to disclosures for purposes other than treatment, payment, or healthcare operations as described in this Notice. Use of your PHI as part of the routine patient care in our practice is not required to be documented. It also excludes disclosures we may have made to you, for a resident directory, to family members or friends involved in your care, or for notification purposes. The right to receive this information is subject to certain exceptions, restrictions, and limitations. Additionally, limitations are different for electronic health records. You may request for an accounting of disclosures by submitting a written request to our Privacy Officer, Melissa Danchak, Kos/Danchak Audiology & Hearing Aids, 101 W. Randol Mill Rd., Ste. 100, Arlington, TX 76011, and provide the reason(s) that support your request.
- Right to Obtain a Paper Copy of this Notice. You are entitled to receive a paper copy of this Notice even if you have agreed to receive this Notice electronically. You may ask us to give you a copy of this Notice at any time. To obtain a paper copy of this notice, you can contact our Privacy Office, Melissa Danchak, at
(817) 277-‐7039 or firstname.lastname@example.org. You may also obtain a copy of this Notice at www.kosdanchakaudiology.com.
- Right to Provide an Authorization for Other Uses and Disclosures. Our practice will obtain your written authorization
- for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your PHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclosure your PHI for the reasons described in the authorization. Please note, we are required to retain records of your care.
COMPLAINTS OR QUESTIONS
If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice or if you have a question about this Notice, please contact our Privacy Office, Melissa Danchak, at (817) 277-‐7039 or email@example.com or the Corporate Privacy Officer at the address listed below. All complaints must be submitted in writing. Kos/Danchak Audiology & Hearing Aids will not retaliate against you for filing a complaint.
CHANGES TO THIS NOTICE
We reserve the right to change this Notice at any time. The new Notice will be effective for all health information our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our practice will post a copy of our current Notice in our office in a visible location at all times, and you may request a copy of our most current Notice at any time. You can also obtain a revised Notice at www.kosdanchakaudiology.com or by contacting our Privacy Office, Melissa Danchak, Kos/Danchak Audiology & Hearing Aids, 101 W. Randol Mill Rd., Ste. 100, Arlington, TX 76011.
Kos/Danchak Audiology & Hearing Aids
Attn: Corporate Privacy Officer
This Notice is effective as of September, 2013.