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NOTICE OF PRIVACY PRACTICES


AC Hearing, Tinnitus and
Balance Associates, LLC

Corporate Office
1776 South Queen Street
York, PA 17403

1-888-252-1776 (IS THIS CORRECT???)
EFFECTIVE: June 27, 2008

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO YOUR MEDICAL INFORMATION. PLEASE REVIEW IT CAREFULLY.

This notice describes the practices of AC Hearing, Tinnitus and Balance Associates, LLC, in connection with the use and disclosure of your medical information and your rights and certain obligations we have regarding the use and disclosure of your medical information. It applies to the Audiologists within our practice who are involved in your care and/or are authorized to enter information into your medical records, and all of our employees, staff and other personnel working in our offices. We are required by law to maintain the privacy of your medical information and to provide you with this notice describing our privacy practices. We are required to abide by the terms of this notice as it is modified from time to time. If the practices described in this notice meet your expectations, there is nothing you need to do. If you prefer that we not share information, we may honor your written request in certain circumstances described below.

WE MAY MAKE CHANGES TO THIS NOTICE IN THE FUTURE, AND ANY OF THE TERMS OF THIS NOTICE THAT ARE CHANGED WILL APPLY TO ALL OF YOUR MEDICAL INFORMATION. IF WE CHANGE OUR NOTICE, YOU MAY OBTAIN A COPY OF THE REVISED NOTICE BY REQUESTING IT IN PERSON AT ANY OF OUR OFFICES OR BY SENDING A WRITTEN REQUEST FOR A COPY TO OUR PRIVACY OFFICER AT THE ABOVE ADDRESS.


OUR PLEDGE REGARDING YOUR MEDICAL INFORMATION
We understand that medical information about you and your health is personal. We are committed to protecting the confidentiality of your medical information. As part of our routine operations, we create a record of your care and services that you receive. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by AC Hearing, Tinnitus and Balance Associates, LLC, whether made by AC Hearing, Tinnitus and Balance Associates, LLC, personnel or your personal doctor.

HOW WE MAY USE OR DISCLOSE YOUR MEDICAL INFORMATION
We are permitted or required to use your medical information for various purposes. We cannot describe every possible use or disclosure of your medical information in this notice. However, uses or disclosures that we are permitted or required to make will generally fall within one of the following categories:

For Treatment: We may use and disclose medical information about you in order to ensure that you receive proper medical treatment. For example, we may disclose your health information to another physician or health care provider involved in your care.

For Payment: We may use and disclose medical information about you so that we obtain payment for the treatment and services we provide to you from you, an insurance company or another third party. For example, we may need to give your health insurance plan information about your diagnosis and a description of the care that we provided to you in order to receive payment for your care.

For Health Care Operations: We may use and disclose medical information about you for our health care operations. Health care operations are activities that are necessary to run our offices, maintain licensure, and to make sure that our patients receive quality care, services and products. For example, we may use your medical information to review our treatment of you and the services we provided and to evaluate the performance of our staff in caring for you. 

Appointment Reminders/Order Status: We may use and disclose medical information to contact you or your personal representative with a reminder postcard or telephone message that it is time for you to call our office and schedule an appointment. We may also contact you by telephone with regard to the status of your hearing aid, earmold, repair or assistive device order.

Treatment Alternatives: We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Individuals Involved in Your Care or Payment for Your Care: We may use and disclose medical information to discuss your medical care with family members or close personal friends who are involved in your medical care or payment for that care. Upon written request you have the right to restrict or refuse any of these uses or disclosures.

As Required By Law: We will disclose medical information about you when required to do so by federal, state or local law.

To Avert a Serious Threat to Health or Safety: We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threatened harm.

SPECIAL DISCLOSURE SITUATIONS

Workers’ Compensation: We may release medical information about you for workers’ compensation or similar programs that provide benefits for work-related injuries or illness as required or permitted by law if you are injured at work.

Health Oversight Activities: We may disclose your medical information to a health oversight agency such as a licensing board for activities authorized by law.

Lawsuits and Disputes: We may disclose medical information about you in response to a court or administrative order, a subpoena, discovery request or other lawful process, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement: Under certain circumstances, we may release medical information about you if asked to do so by a law enforcement official.

Government Purposes: We may release your medical information under limited circumstances if you are a member of the armed forces or foreign military personnel, or for intelligence, counter-intelligence and other national security activities authorized by law.

Incidental Uses and Disclosures: We may use or disclose your medical information if it is a by-product of any of the uses or disclosures described above and it could not be reasonably prevented.

Limited Data Sets: We may use or disclose certain information that does not directly identify you for research, public health or health care operations if the recipient of that information agrees to protect the information.

DISCLOSURES WITH YOUR AUTHORIZATION
We must obtain your authorization to use or disclose health information in those situations not otherwise described in this Notice. If you do authorize us to use or disclose your medical information, you have the right to revoke that authorization at anytime.

YOUR RIGHTS IN CONNECTION WITH YOUR MEDICAL INFORMATION
You have the following rights in connection with the medical information we maintain about you:

Right to Inspect and Copy: You have the right to inspect and copy your medical information that is in our possession. You may not, however, have access to information that is put together for use in a civil, criminal or administrative proceeding.

To inspect or copy your medical information, you must submit your request in writing to our corporate office. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.

We may deny your request to inspect or copy your health information in certain very limited circumstances. If you are denied access to your medical information, you may be able to request that the denial be reviewed. Another licensed health care professional chosen by AC Hearing, Tinnitus and Balance Associates, LLC, will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Right to Request Amendment: If you feel that your medical information is incorrect or incomplete, you may ask us to amend that information. You have the right to request an amendment for as long as the information is kept by or for our office. To request an amendment, your request must be made in writing and submitted to our corporate office. You must explain why you believe that the medical information is incorrect or incomplete. If we deny your request, you have a right to give us a short statement to be placed with your medical information or to have us include your request for amendment with your medical information.

Right to an Accounting of Disclosures: You have the right to request, and we must provide you with, a list of certain disclosures of your medical information. We are not required to include on that, any disclosures to carry out your treatment, payment for your care, and other health care operations and certain other disclosures. To request this list or accounting of disclosures, you must submit your request in writing to our corporate office.
Your request must state a time period covered by your request. That time period may not be longer than six years and may not include dates before June 27, 2008. Your request should indicate in what form you want the list (for example, on paper or electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions: You have the right to request additional restrictions from those detailed in this notice. Your request must be submitted in writing to our corporate office. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply. We are not required, however, to agree to your request.

Right to Request Confidential Communication: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. Your request must specify how or where you wish to be contacted. To request confidential communications, you must make your request in writing to our corporate office. We will not ask you the reason for your request and we will accommodate all reasonable requests.

Right to a Paper Copy of this Notice: You may ask us to give you a copy of this notice at any time by asking for it in person or in writing. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the United States Department of Health and Human Services, Office of Civil Rights at 1-866-627-7748. To file a complaint with us, contact our corporate office in writing. You will not be penalized for filing a complaint.

If you have any questions about this notice, please contact our Privacy Officer at the address listed above.

Modified 06/27/2008


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