* For Payment. We may use and disclose medical information about you
so that the treatment and services you receive at the facility may be billed
to and payment may be collected from you, an insurance company, or a third party.
We may also tell your health plan about a treatment you are going to receive
to obtain prior approval or to determine whether your plan will cover the treatment.
* For Health Care Operations. We may use and disclose medical information about
you for facility operations. These uses and disclosures are necessary to run
the facility and make sure that all of our patients receive quality care. For
example, we may use medical information to review our treatment and services
and to evaluate the performance of our staff in caring for you. We may also
combine medical information about many facility patients to decide what additional
services the facility should offer, what services are not needed, and whether
certain new treatments are effective. We may also disclose information to doctors,
nurses, technicians, medical students, and other facility personnel for review
and learning purposes. We may also combine the medical information we have with
medical information from other facilities to compare how we are doing and see
where we can make improvements in the care and services that we offer. We may
remove information that identifies you from this set of medical information
so others may use it to study health care and health care delivery without learning
the names of specific patients.* Appointment Reminders. We may use and disclose
medical information to contact you as a reminder that you have an appointment
for treatment or medical care at the facility. Office personnel may attempt
to contact you as a reminder of upcoming appointments or to report test results.
These reminders or test results may be left on answering machines at the phone
numbers you have supplied to us. If you wish to make other arrangements or desire
for the office to refrain from leaving such messages, please advise the office
in writing so that we place such a request into your medical record.* Treatment
Alternatives. We may use and disclose medical information to tell you about
or recommend possible treatment options or alternatives or products that may
be of interest to you. * Health-Related Benefits and Services. We may use and
disclose medical information to tell you about health-related benefits or services
that may be of interest to you.
* Individuals Involved in Your Care or Payment for Your Care. We may
release medical information about you to a friend or family member who is involved
in your medical care. We may also give information to someone who helps pay
for your care. We may also tell your family or friends your condition and that
you are in the facility. In addition, we may disclose medical information about
you to an entity assisting in a disaster relief effort so that your family can
be notified about your condition, status and location.* Research. Under certain
circumstances, we may use and disclose medical information about you for research
purposes. For example, a research project may involve comparing the health and
recovery of all patients who received one medication to those who received another,
for the same condition. All research projects, however, are subject to a special
approval process. This process evaluates a proposed research project and its
use of medical information, trying to balance the research needs with patients'
need for privacy of their medical information. Before we use or disclose medical
information for research, the project will have been approved through this research
approval process. We will ask for your specific permission if the researcher
will have access to your name, address or other information that reveals who
you are, or will be involved in your care at the facility. * 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 threat.
Special Disclosure Situations
* Military and Veterans. If you are a member of the armed forces, we
may release medical information about you as required by military command authorities.
We may also release medical information about foreign military personnel to
the appropriate foreign military authority.
* Workers' Compensation. We may release medical information about you to Workers' Compensation or similar programs. These programs provide benefits for work-related injuries or illness.
* Public Health Risks. We may disclose medical information about you for public health activities. These activities generally include the following:
* To prevent or control disease, injury or disability
* To report births and deaths
* To report child abuse or neglect
* To report reactions to medications or problems with products
* To notify people of recalls of products they may be using
* To notify a person who may have been exposed to a disease or may be at risk
for contracting or spreading a disease or condition
* To notify the appropriate government authority if we believe a patient has
been the victim of abuse, neglect or domestic violence. We will only make this
disclosure if you agree or when required or authorized by law
* Health Oversight Activities. We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
* Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
* Law Enforcement. We may release medical information if asked to do so by a law enforcement official, including the following situations:
* In response to a court order, subpoena, warrant, summons or similar process;
* To identify or locate a suspect, fugitive, material witness, or missing person;
* About the victim of a crime if, under certain limited circumstances, we are
unable to obtain the person's agreement;
* About a death we believe may be the result of criminal conduct;
* About criminal conduct at the facility; and
* In emergency circumstances to report a crime; the location of the crime or
victims; or the identity, description or location of the person who committed
the crime.
* Coroners, Medical Examiners, and Funeral Directors. We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about patients of the facility to funeral directors as necessary to carry out their duties.
* National Security and Intelligence Activities. We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
* Protective Services for the President and Others. We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.
* Inmates. If you are an inmate of a correctional institution or under
the custody of a law enforcement official, we may release medical information
about you to the correctional institution or law enforcement official. This
release would be necessary (1) for the institution to provide you with health
care; (2) to protect your health and safety or the health and safety of others;
or (3) for the safety and security of the correctional institution.
Your Rights Regarding Medical Information About You
You have the following rights regarding medical information we maintain about
you:
* Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes.
To inspect and copy medical information that may be used to make decisions about
you, you must submit your request in writing to Marian Fredner, Albemarle Audiology,
3042-A1 Berkmar Drive, Charlottesville, VA 22901. 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 and copy in certain very limited circumstances.
If you are denied access to medical information, you may request that the denial
be reviewed. Another licensed health care professional chosen by the facility
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 Amend. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the facility.
To request an amendment, your request must be made in writing and submitted
to Marian Fredner, Albemarle Audiology, 3042-A1 Berkmar Drive, Charlottesville,
VA 22901. In addition, you must provide a reason that supports your request.
We may deny your request for an amendment if it is not in writing or does not
include a reason to support the request. In addition, we may deny your request
if you ask us to amend information that:
* Was not created by us, unless the person or entity that created the information
is no longer available to make the amendment;
* Is not part of the medical information kept by or for the facility;
* Is not part of the information which you would be permitted to inspect and
copy; or
* Is accurate and complete.
* Right to an Accounting of Disclosures. You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of medical information about you.
To request this list or accounting of disclosures, you must submit your request
in writing to Marian Fredner, Albemarle Audiology, 3042-A1 Berkmar Drive, Charlottesville,
VA 22901. Your request must state a time period that may not be longer than
six years and may not include dates before February 26, 2003. Your request should
indicate in what form you want the list (i.e., 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 a restriction or limitation on the medical information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care, like a family member or friend. For example, you could ask that we not use or disclose information about a medical procedure that you had.
We are not required to agree to your request. If we do agree, we will comply
with your request unless the information is needed to provide you emergency
treatment.
To request restrictions, you must make your request in writing to Marian Fredner,
Albemarle Audiology, 3042-A1 Berkmar Drive, Charlottesville, VA 22901. 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, for example, disclosures to your spouse.
* Right to Request Confidential Communications. 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.
To request confidential communications, you must make your request in writing
to Marian Fredner, Albemarle Audiology, 3042-A1 Berkmar Drive, Charlottesville,
VA 22901. We will not ask you the reason for your request. We will accommodate
all reasonable requests. Your request must specify how or where you wish to
be contacted.
* Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.
You may obtain a copy of this notice at our website, www.HearBetterNow.com.
To obtain a paper copy of this notice, send a request to Marian Fredner, Albemarle
Audiology, 3042-
A1 Berkmar Drive, Charlottesville, VA 22901.
Changes to this Notice
We reserve the right to change this notice. We reserve the right to make the
revised or changed notice effective for medical information we already have
about you as well as any information we receive in the future. We will post
a copy of the current notice in the facility. The notice will contain on the
first page, in the top right-hand corner, the effective date. In addition, each
time you register at or are admitted to the facility for treatment or health
care services we will offer you a copy of the current notice in effect.
Complaints
If you believe your privacy rights have been violated, you may file a complaint
with Albemarle Audiology or with the Secretary of the Department of Health and
Human Services (202) 619-0257. To file a complaint with Albemarle Audiology,
contact Marian Fredner, Albemarle Audiology, 3042-A1 Berkmar Drive, Charlottesville,
VA 22901. All complaints must be submitted in writing.
You will not be penalized for filing a complaint.
Other Uses of Medical Information
Other uses and disclosures of medical information not covered by this notice
or the laws that apply to us will be made only with your written permission.
If you provide us permission to use or disclose medical information about you,
you may revoke that permission, in writing, at any time. If you revoke your
permission, we will no longer use or disclose medical information about you
for the reasons covered by your written authorization. You understand that we
are unable to take back any disclosures we have already made with your permission,
and that we are required to retain our records of the care that we provided
to you.
Attestation
By initialing and dating the form below I acknowledge that I have received or
reviewed a copy of Albemarle Audiology Privacy Notice.
I hereby acknowledge that I have received or reviewed a copy of this practice’s
Notice of Privacy Practices.
____________________________
Signature
____________________________ ___________________
Name (Printed) Date