Privacy Officer: Deborah Pitcher
Effective Date: April 14, 2003

Notice of Privacy Practices

This notice describes how audiological information obtained at this office may be used and disclosed and how you can get access to this information. Please review it carefully and provide your signature for acknowledgement.

Bloomington – Normal Audiology (BNA) cares about our patient’s privacy and we strive to protect the confidentiality of your audiological and medical information kept at this office. It is now federal regulation that we provide you this official notice of our privacy practices. You have the right to the confidentiality of your audiological information, and this practice is required by law to maintain the privacy of that protected health information. BNA is required to abide by the terms of the Notice of Privacy Practices (NPP) currently in effect, and to provide notice of its’ legal duties and privacy practices with respect to protected health information. If you have any questions about this NPP, please contact the Privacy Officer at this practice.

Who Will Follow This Notice

Any audiologist(s) that are authorized to enter information into your medical record, and all other employees at this practice who may need access to your information must abide by this Notice. All business associates (e.g. hearing aid manufacturers, billing services), sites and locations of this practice my share audiological information with each other for treatment, payment purposes or health care operations described in this notice. Except where treatment is involved, only the minimum necessary information needed will be shared.

How We May Use and Disclose Medical Information About You

The following categories describe different ways that we may disclose medical information without your specific consent or authorization. Examples are provided for each category of disclosures. Not every possible use or disclosure in a category is listed.

For Treatment: We may use audiological information about you to provide you with medical treatment or services. Example: In ordering a hearing aid for you we may disclose your audiogram and speech audiometry results.

For Payment: We may use and disclose audiological information about you so that the treatment and services you receive from us may be billed and payment may be collected from you, an insurance company, or a third party. Example: We may need to send your protect health information such as your name, address, office visit date, and codes identifying your diagnosis and treatment to your insurance company for payment.

For Health Care Operations: We may use and disclose audiological information about you for health care operations to assure that you receive quality care. Example: We may use your medical information to review our treatment and services and evaluate the performance of our staff in caring for you.

Other Uses or Disclosures That Can Be Made Without Consent or Authorization

• We may disclose your Protected Health Information (PHI) for law enforcement purposes as required by law or in response to a subpoena or court order.
• As required by law we may disclose your PHI to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
• To worker’s compensation or similar programs for processing of claims
• In response to legal proceedings
• To a coroner or medical examiner for identification of a body
• If an inmate, to the correctional institution or law enforcement official
• As required by the Food and Drug Administration (FDA)
• Other healthcare provider’s treatment activities
• Other covered entities’ and providers’ payment activities
• Other covered entities’ healthcare operations activities (to the extent permitted under HIPAA)
• Uses and disclosures required by law
• Uses and disclosures in domestic violence or neglect situations
• Health oversight activities
• Other public health activities

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.

Uses and Disclosures of Protected Health Information Requiring Your Written Authorization

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 authorization. If you give us authorization to use or disclose audiological information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will thereafter no longer use or disclose audiological 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 authorization, and that we are required to retain our records of the care we have provided you.

Your Individual Rights Regarding Your Medical Information

Complaints. If you believe your privacy rights have been violated, you may file a complaint with the Privacy Officer at this practice or with the Department of Health and Human Services. All complaints must be submitted in writing. You will not be penalized or discriminated against for filing a complaint.

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 or to someone who is involved in your care or the payment for your care. We are not required to agree to your request. If we do agree, will comply with your request unless the information is needed to provide you with emergency treatment. To request restrictions, you must submit your request in writing to the Privacy Officer at this practice. In your request, you must tell us what information you want to limit.

Right to Request Confidential Communications. You have the right to request how we submit communications to you about your audiological matters, and where you would like those communications sent. To request confidential communications, you must make your request to the Privacy Officer at this practice. We will not disclose the reason for your request. We will accommodate all reasonable requests. Your request must specify how or when you wish to be contacted. We reserve the right to deny a request if it imposes an unreasonable burden on the practice.

Right to Inspect and Copy. You have the right to inspect and copy audiological information used to make decisions about your care. Usually this includes medical and billing records but does not include chart notes. We may charge you a fee for the costs of copying, mailing, and supplies that are necessary to fulfill your request. It is our right to deny your request to inspect and copy in certain limited circumstances.

Right to Amend. If you feel that audiological 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. To request an amendment, your request must be made in writing and submitted to the Privacy Officer at this practice. You must include a reason(s) that supports your request. Amendments may be denied.

Right to a Paper Copy of this Notice. You have the right to a paper 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. To obtain a paper copy of the current Notice, please request one in writing from the Privacy Officer at this practice.

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 audiological 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, with the effective date in the upper right corner of the first page.

Where to obtain forms for submitting written requests. You may obtain forms for submitting written request by contacting the Privacy Officer at Bloomington – Normal Audiology, 1404 Eastland Drive, Suite 203, Bloomington, IL 61701.