SUMMARY 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
TREATMENT:Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions and providing treatment. For example, a doctor may use the information in your medical record to determine which treatment option, such as a drug or surgery, best addresses your health needs.
PAYMENT: Your health information may be used to seek payment from your health plan or from other sources of coveragesuch as auto insurer or from credit card companies that you may use to pay for services.
HEALTH CARE OPERATIONS: Your health information may be used, as necessary, to support day-to-day activities and management of Hearing Evaluation Services. For example, information may be used to support budgeting and financial reporting activities to evaluate and promote quality.
LAW ENFORCEMENT: Your health information may be disclosed to law enforcement agencies to support government audits and inspections, to facilitate law enforcement investigations, and to comply with government mandated reporting.
PUBLIC HEALTH REPORTING: Your health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the public health department.
OTHER USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION: Other disclosure of your health information or its use for other than the reasons listed above requires specific and written authorization. If you change your mind after authorizing, you may submit a written revocation of the authorization. However, your revocation will not affect or undo any use or disclosure that occurred before you notified us of your decision.
ADDITIONAL USES OF INFORMATION: Your health information will be used by our staff to send any appointment reminders deemed necessary.
INDIVIDUAL RIGHTS
: You have certain rights under federal privacy standards including:
· The right to request restrictions on the use and disclosure of your health information.
· The right to receive confidential communications concerning your medical condition and treatment.
· The right to inspect and copy your health information
· You can request to amend or submit corrections to your health information
· The right to receive an accounting of how and to whom your health information was disclosed
· The right to receive a printed copy of this summary and Hearing Evaluation Services Notice of Privacy Practices, which provide a more complete description of information uses and disclosures
HEARING EVALUATION SERVICES OF BUFFALO, INC. DUTIES: We are required to maintain the privacy of your health information and to provide you with our Notice of Privacy Practices. We reserve the right to amend or modify our privacy policies and practices. Upon request we will provide you with the most recently revised notice on any office visit. The revised policies and practices will be applied to all protected health information we maintain.
· You may generally inspect or copy your health information. As permitted by federal regulation we require that such request must be submitted in writing to: Hearing Evaluation Services. Your request will be reviewed and generally accepted unless there are legal or medical reasons to deny your request.
· If you would like to submit a comment or complaint about our privacy practices (you will not be penalized or otherwise retaliated against for filing) you may submit a letter outlining your concerns to: Anne P. Orsene, Au.D., Director, Hearing Evaluation Services, 4600 Main St., Ste. 201, Amherst, NY 14226
· For further information concerning our privacy practices, please contact Anne P. Orsene, Au.D., Director
· The effective date of this notice is April 14, 2003