Audiological Diagnostics, P.C.

Effective date: April 22, 2003

Audiological Diagnostics, P.C.

Privacy Notice

This document describes the type of information Audiological Diagnostics, P.C. gathers about you, with whom that information may be shared, and the safeguards we have in place to protect it. This medical information is commonly referred to as "protected health information," or "PHI" for short. PHI includes information that can be used to identify you, the provision of health care to you, or the payment of this health care. You have the right to the confidentiality of your PHI and the right to approve or refuse the release of specific information except when the release is required by law. 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. If you have any questions regarding this Privacy Notice, please contact our Privacy Officer, via telephone or (718) 745-2826, or via email at This e-mail address is being protected from spambots. You need JavaScript enabled to view it. .

Who Will Follow This Notice?

This notice describes Audiological Diagnostics, P.C.’s practices and that of:

• Any health care professional authorized to enter information into your chart
• All departments and units of Audiological Diagnostics, P.C., its clinics, and other affiliates
• Any member of a volunteer group we allow to help you while you are in Audiological Diagnostics, P.C.
• All employees, staff and other facility personnel

All these entities, sites and locations follow the terms of this notice. In addition, these entities, sites and locations may share medical information with each other for purposes of treatment, payment, or healthcare operations described in this notice.

Our Pledge Regarding Medical Information

We understand that PHI/medical information about you and your health is personal. We are committed to protecting the confidentiality of your PHI. As part of our routine operations, we create a record of the care and services 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 Audiological Diagnostics, P.C., whether made by Audiological Diagnostics, P.C. personnel or your personal doctor. Your personal doctor may have different policies or notices regarding the doctor's use and disclosure of your medical information created in the doctor's office or clinic.

This notice will tell you about the ways in which we may use and disclose PHI about you. We also describe your rights and certain obligations we have regarding the use and disclosure of PHI.

Federal law requires us to:

• Make sure that PHI that identifies you is kept private
• Give you this notice of our legal duties and privacy practices with respect to PHI about you
• Follow the terms of the notice that is currently in effect

   

How We May Use and Disclose Medical Information About You

The following categories describe different ways that we use and disclose PHI. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

We may disclose your PHI to business associates to provide a service, i.e. an equipment vendor who installs, maintains and upgrades the equipment at our facility. To the extent that we are required to disclose your PHI to contractors, agents, or other business associates, we will have a written contract to ensure that our business associate also protects the privacy of your PHI.

• For Treatment
. We may use your PHI to provide you with medical treatment or services. We may disclose PHI about you to audiologists, dispensers, students, or other facility personnel who are involved in taking care of you at the facility. We also may disclose PHI about you to people outside the facility who may be involved in your medical care after you leave the facility, such as another health care provider to whom you have been referred for further care, hearing aid and earmold manufacturers when we order a hearing aid for you, family members, clergy, or others we use to provide services that are part of your care. We may request copies of your PHI from another professional that you may have seen before us to diagnose or treat you. The PHI may be exchanged via the telephone, mail or fax.
• For Payment
. We may use and disclose PHI about you to bill and collect payment from you, an insurance company, or a third party for services received at Audiological Diagnostics, P.C. For example, we may need to give your health plan information about procedures you received at Audiological Diagnostics, P.C. so your health plan will pay us or reimburse you for the them. 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 PHI 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 PHI to contact you as a reminder that you have an appointment for treatment or medical care at Audiological Diagnostics, P.C.. It is our office policy to call the phone numbers you have provided to set up or confirm appointments or to advise you that we have devices ready for you to pick up. We will phone you at the numbers you have provided. If we cannot speak with you directly, we will leave a message on a recording or with the person who answers the phone. We will mail you reminders of warranty expirations to the address on file here. If you do not agree with the policies in this paragraph, you must advise us in writing.
• Individuals Involved in Your Care or Payment for Your Care
. We may release PHI about you to a friend, family member or other person 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. If you do not want us to do this, please notify us in writing.
• Sharing your PHI at your request. If you want your information forwarded to another agency or provider or individual, we must first have your prior written consent to FAX, mail, or discuss your PHI with them in person or by phone.
• Treatment Alternatives
. We may use and disclose PHI to tell you about or recommend possible treatment options or alternatives 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. This may include information in special mailings about new products and services available at Audiological Diagnostics, P.C. We will not provide your name and address to an outside entity for marketing purposes.
• As Required By Law
. We will disclose medical information about you when required to do so by federal, state or local law, judicial or administrative proceedings or law enforcement.
• Research
. Under certain circumstances, we may use and disclose PHI 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 PHI, trying to balance the research needs with patients' need for privacy of their PHI. Before we use or disclose medical information for research, the project will have been approved through this research approval process, but we may, however, disclose medical information about you to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, so long as the medical information they review does not leave the facility. We will almost always 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.
• 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.
• De-identified Information. We may also disclose your PHI if it has been de-identified or unable to for anyone to connect back to you. This might occur if you are participating in a research project.

• Incidental Disclosures. While we will take reasonable steps to safeguard the privacy of your PHI, certain disclosures of your PHI may occur during, or as an unavailable result of our otherwise permissible uses or disclosures of your health information. For example, during the course of a treatment session, other patients in the treatment area may see, or overhear discussion of your PHI.

Special Disclosure Situations

-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

- 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.

• Organ and Tissue Donation
. If you are an organ donor, we may release PHI to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.
• Military and Veterans
. If you are a member of the armed forces, we may release PHI about you as required by military command authorities. We may also release PHI about foreign military personnel to the appropriate foreign military authority.
• Workers' Compensation
. We may release PHI about you to Workers' Compensation or similar programs. These programs provide benefits for work-related injuries or illness.
• Public Health Risks
. We may disclose PHI about you for public health activities. These activities generally include the following:
• Health Oversight Activities
. We may disclose PHI 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 PHI about you in response to a court or administrative order. We may also disclose PHI 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 PHI if asked to do so by a law enforcement official, including the following situations:
• National Security and Intelligence Activities
. We may release PHI 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 PHI 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 PHI 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:

To inspect and copy PHI that may be used to make decisions about you, you must submit your request in writing to Audiological Diagnostics, P.C.. 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 PHI, 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.

To request an amendment, your request must be made in writing and submitted Audiological Diagnostics, P.C.. 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 PHI 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.

To request this list or accounting of disclosures, you must submit your request in writing Audiological Diagnostics, P.C.. 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.

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. You may not limit the uses and disclosures that we are legally required or allowed to make.

To request restrictions, you must make your request in writing to Audiological Diagnostics, P.C. 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.

To request confidential communications, you must make your request in writing to Audiological Diagnostics, P.C. 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 Inspect and Copy
. You have the right to inspect and copy PHI that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes.
• Right to Amend
. If you feel that PHI 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.
• 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 PHI about you. The list will not include uses or disclosures that you have already been informed of, such as those made for treatment, payment or healthcare operations, directly to you, to your family or in our facility directory. The list will also won’t include uses and disclosures made for national security purposes, to corrections or law enforcement personnel or before April 14, 2003.
• Right to Request Restrictions
. You have the right to request a restriction or limitation on the PHI we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the PHI 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.
• 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.
• 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, http://www.audiodx.com

To obtain a paper copy of this notice, contact Audiological Diagnostics, P.C.

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 PHI 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 as an inpatient or outpatient, 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 Audiological Diagnostics, P.C. or with the Secretary of the Department of Health and Human Services. To file a complaint with Audiological Diagnostics, P.C., contact the Privacy Officer at (718) 745-2826. 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 PHI 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 PHI about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose PHI 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 a copy of Audiological Diagnostics, P.C.’s Privacy Notice.

____________________________________ _______________________________

Signature of Patient or Patient Representative Date

If Representative, relation to Patient:________________________________________________

For questions, e-mail us at This e-mail address is being protected from spambots. You need JavaScript enabled to view it.


447 77th Street
Brooklyn, NY 11209
718-745-2826