NOTICE 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.
PLEASE REVIEW IT CAREFULLY.
I. Who We Are
This Notice describes the privacy practices of your home healthcare company.
II. Our Privacy Obligations
We are required by law to maintain the privacy of your health information
("Protected Health Information" or "PHI") and to provide you with this Notice of our
legal duties and privacy practices with respect to your Protected Health Information.
When we use or disclose your Protected Health Information, we are required to
abide by the terms of this Notice (or other notice in effect at the time of the use or
III. Permissible Uses and Disclosures Without Your Written Authorization
In certain situations, which we will describe in Section IV below, we must obtain your
written authorization in order to use and/or disclose your PHI. However, we do not need
any type of authorization from you for the following uses and disclosures:
A. Uses and Disclosures for Treatment, Payment and Healthcare Operations.
We may use and disclose PHI, but not your "Highly Confidential Information"
(defined in Section IV. C below), in order to treat you, obtain payment for equipment
and services provided to you and conduct our "healthcare operations" as detailed below:
Treatment. We use and disclose your PHI to provide treatment and other services
to you -- for example, to treat your injury or illness. In addition, we may contact you to
provide appointment reminders or information about treatment alternatives or other
health- related benefits and services that may be of interest to you. We may also
disclose PHI to other providers involved in your treatment.
Payment. We may use and disclose your PHI to obtain payment for equipment and
services that we provide to you -- for example, disclosures to claim and obtain
payment from your health insurer, HMO, or other company that arranges or pays
the cost of some or all of your healthcare (Your Payor") to verify that Your Payor will
pay for healthcare.
Healthcare Operations. We may use and disclose your PHI for our healthcare
operations, which include internal administration and planning and various activities
that improve the quality and cost effectiveness of the care that we deliver to you.
For example, we may use PHI to evaluate the quality and competence of our respiratory
therapists, nurses and other healthcare workers.
We may also disclose PHI to your other healthcare providers when such PHI is
required for them to treat you, receive payment for services they render to you, or
conduct certain healthcare operations, such as quality assessment and improvement
activities, reviewing the quality and competence of healthcare professionals, or for
healthcare fraud and abuse detection or compliance.
B. Disclosure to Relatives, Close Friends and Other Caregivers. We may use or
disclose your PHI to a family member, other relative, a close personal friend or any
other person identified by you when you are present for, or otherwise available prior
to, the disclosure, if we (1) obtain your agreement; (2) provide you with the opportunity
to object to the disclosure and you do not object; or (3) reasonably infer that you do not
object to the disclosure. If you are not present, or the opportunity to agree or object to a
use or disclosure cannot practicably be provided because of your incapacity or an
emergency circumstance, we may exercise our professional judgment to determine
whether a disclosure is in your best interests. If we disclose information to a family
member, other relative or a close personal friend, we would disclose only information
that we believe is directly relevant to the person?s involvement with your healthcare or
payment related to your healthcare. We may also disclose your PHI in order to notify
(or assist in notifying) such persons of your location, general condition or death.
C. Public Health Activities. We may disclose your PHI for the following public health
activities: (1) to report health information to public health authorities for the purpose of
preventing or controlling disease, injury or disability; (2) to report child abuse and
neglect to public health authorities or other government authorities authorized by law
to receive such reports; (3) to report information about products and services under the
jurisdiction of the U. S. Food and Drug Administration; (4) to alert a person who may
have been exposed to a communicable disease or may otherwise be at risk of
contracting or spreading a disease or condition; and (5) to report information to
your employer as required under laws addressing work- related illnesses and
injuries or workplace medical surveillance.
D. Victims of Abuse, Neglect or Domestic Violence. If we reasonably believe you
are a victim of abuse, neglect or domestic violence, we may disclose your PHI
to a governmental authority, including a social service or protective services
agency, authorized by law to receive reports of such abuse, neglect, or
E. Health Oversight Activities. We may disclose your PHI to a health oversight
agency that oversees the healthcare system and is charged with responsibility
for ensuring compliance with the rules of government health programs such
as Medicare or Medicaid.
F. Judicial and Administrative Proceedings. We may disclose your PHI in the
course of a judicial or administrative proceeding in response to a legal order
or other lawful process.
G. Law Enforcement Officials. We may disclose your PHI to the police or
other law enforcement officials as required or permitted by law or in compliance
with a court order or a grand jury or administrative subpoena.
H. Decedents. We may disclose your PHI to a coroner or medical examiner
as authorized by law.
I. Organ and Tissue Procurement. We may disclose your PHI to organizations
that facilitate organ, eye or tissue procurement, banking or transplantation.
J. Research. We may use or disclose your PHI without your consent or
authorization if an Institutional Review Board or Privacy Board approves
a waiver of authorization for disclosure.
K. Health or Safety. We may use or disclose your PHI to prevent or lessen
a serious and imminent threat to a person?s or the public?s health or safety.
L. Specialized Government Functions. We may use and disclose your
PHI to units of the government with special functions, such as the U. S.
military or the U. S. Department of State under certain circumstances.
M. Workers' Compensation. We may disclose your PHI as authorized
by and to the extent necessary to comply with state law relating to workers?
compensation or other similar programs.
N. As Required by Law. We may use and disclose your PHI when required
to do so by any other law not already referred to in the preceding categories.
IV. Uses and Disclosures Requiring Your Written Authorization
A. Use or Disclosure with Your Authorization. For any purpose other than the
ones described above in Section III, we only may use or disclose your PHI
when you grant us your written authorization ("Your Authorization"). For instance,
you will need to execute an authorization before we can send your PHI to your
life insurance company or to the attorney representing the other party in
litigation in which you are involved.
B. Marketing. We must also obtain your written authorization ("Your Marketing
Authorization") prior to using your PHI to send you any marketing materials.
(We can, however, provide you with marketing materials in a face- to- face
encounter without obtaining Your Marketing Authorization. We are also
permitted to give you a promotional gift of nominal value, if we so choose,
without obtaining Your Marketing Authorization.) In addition, we may
communicate with you about products or services relating to your treatment,
case management or care coordination, or alternative treatments, therapies,
providers or care settings without Your Marketing Authorization.
C. Uses and Disclosures of Your Highly Confidential Information. In addition,
federal and state law require special privacy protections for certain highly
confidential information about you ("Highly Confidential Information").
We will comply with such special privacy protections which may cover the
subset of your PHI that: (1) is maintained in psychotherapy notes; (2) is
about mental health and developmental disabilities services; (3) is about
alcohol and drug abuse prevention, treatment and referral; (4) is about
HIV/AIDS testing, diagnosis or treatment; (5) is about venereal disease(s);
(6) is about genetic testing; (7) is about child abuse and neglect; (8) is about
domestic abuse of an adult with a disability; (9) is about sexual assault; or
(10) is about abortion.
V. Your Rights Regarding Your Protected Health Information
A. For Further Information; Complaints. If you desire further information about
your privacy rights, are concerned that we have violated your privacy rights or
disagree with a decision that we made about access to your PHI, you may
contact our Physician and Patient Relations Department. You may also file
written complaints with the Director, Office for Civil Rights of the U. S.
Department of Health and Human Services. Upon request, the Physician
and Patient Relations Department will provide you with the correct address
for the Director. We will not retaliate against you if you file a complaint with us
or the Director.
B. Right to Request Restrictions. You may request restrictions on our use
and disclosure of your PHI (1) for treatment, payment and healthcare operations;
(2) to individuals (such as a family member, other relative, close personal
friend or any other person identified by you) involved with your care or with
payment related to your care; or (3) to notify or assist in the notification of
such individuals regarding your location and general condition. While we will
consider all requests for restrictions carefully, we are not required to agree to
a requested restriction. If you wish to request restrictions, please submit a
written request to our Physician and Patient Relations Department. A form to
request restrictions is available upon request from the Physician and Patient
C. Right to Receive Confidential Communications. You may request, and we
will accommodate, any reasonable written request for you to receive your PHI
by alternative means of communication or at alternative locations.
D. Right to Revoke Your Authorization. You may revoke Your Authorization, Your
Marketing Authorization or any written authorization obtained in connection
with your Highly Confidential Information, except to the extent that we have
taken action in reliance upon it, by delivering a written revocation statement
to the Physician and Patient Relations Department identified below. A form of
written revocation is available upon request from the Physician and Patient
E. Right to Inspect and Copy Your Health Information. You may request
access to your medical record file and billing records maintained by us in order
to inspect and request copies of the records. Under limited circumstances,
we may deny you access to a portion of your records. If you desire access to
your records, please submit a written request to the Physician and Patient
Relations Department. You may obtain a record request form from the
Physician and Patient Relations Department and submit the completed
form to the Physician and Patient Relations Department. Requests for a
copy of a limited amount of your medical or billing records (e. g., a prescription)
maintained by us on- site may be made orally to our local facility. We may,
however, require that you submit a written request to the Physician and Patient
F. Right to Amend Your Records. You have the right to request that we amend
Protected Health Information maintained in your medical record file or billing
records. If you desire to amend your records, please send a written request
for the amendment, including the reason for the amendment, to the Physician
and Patient Relations Department. You may obtain a form to request an
amendment from the Physician and Patient Relations Department. We will
comply with your request unless we believe that the information that would
be amended is accurate and complete or other special circumstances apply.
G. Right to Receive an Accounting of Disclosures. Upon request, you may
obtain an accounting of certain disclosures of your PHI made by us during
any period of time prior to the date of your request provided such period
does not exceed six years and does not apply to disclosures that occurred
prior to April 14, 2003.
H. Right to Receive Paper Copy of This Notice. Upon request, you may
obtain a paper copy of this Notice, even if you have agreed to receive such
VI. Effective Date and Duration of This Notice
A. Effective Date. This Notice is effective as of April 14, 2003.
B. Right to Change Terms of This Notice. We reserve the right to, meaning
we may, change the terms of this Notice at any time. If we change this
Notice, we may make the new notice terms effective for all Protected
Health Information that we maintain, including any information created
or received prior to issuing the new notice. If we change this Notice, we
will post the new notice in waiting areas at our facility and on our Internet
site. You also may obtain any new notice by contacting the Physician and
Patient Relations Department.
VII. Privacy Officer
You may contact the Privacy Officer at :
Beltone Hearing Care Center
165 E Rowland
Covina, CA 91723
Acknowledgement of Notice of Privacy Practices
By my signature below, I hereby acknowledge that I have received a
copy of the Notice of Privacy Practices of Beltone New England. I have read
and understand and I have had an opportunity to ask questions about
the use and disclosure of my protected health information, and other
concerns regarding my protected health information.
Signature of Patient (or Personal Representative)
Printed Name of Patient (or Personal Representative)
Legal Authority of Personal Representative
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