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Privacy Policy 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. Dr. Keith Ergle Effective Date of This Notice: Southeastern Hearing
Services, Inc. collects health information from you and stores it
in a chart and on a computer. This
is your medical record. We
need this record to provide you with quality care and to comply with
certain legal requirements. The medical record is the property of Southeastern
Hearing Services, Inc. but the information in the medical record
belongs to you. Southeastern
Hearing Services, Inc. protects the privacy of your health information. We understand that clinical information about
you and your health is personal. We
are committed to protecting clinical information for you. This notice applies to all of the records of
your care generated or maintained by Southeastern Hearing Services,
Inc. This notice will tell you about ways in which we may use and
disclose clinical information about you. The
law permits Southeastern Hearing Services, Inc. to use or disclose
your health information for the following purposes: 1. Treatment. We may use clinical information about you to
provide, coordinate, or manage your clinical treatment and /or related
services. We may disclose
clinical information about you to clinicians, physicians, nurses,
others inside and outside of Southeastern Hearing Services, Inc.
who are involved in taking care of you. For
example, hearing evaluation information may be shared in order to
coordinate further medical treatment, including the ordering of hearing
aids. We may also disclose
clinical information, as necessary, to other professionals who may
be treating you or to whom you have been referred. This is to ensure they have the necessary information
to diagnose or treat you. We
may use and disclose your clinical information to tell you about
or recommend possible treatment options or alternatives that may
be of interest to you. 4. Information
provided to you. Information
provided to you by another professional that will be helpful in
the treatment, care and operation of your healthcare can be provided
directly to Southeastern Hearing Services, Inc. by you. Also,
health care information provided to you by Southeastern Hearing
Services, Inc. can be provided to others by you for any use you
declare. 5. Business associates. There are some services provided by Southeastern
Hearing Services through contracts with business associates. An example would be companies that provide
assistive listening devices, including hearing aids. When these companies are contacted, we may
need to disclose your health information so they can perform the
job we have asked them to. To
protect your health information, however, we require the business
associate to appropriately safeguard your information. 6. Directory. We may list your name, address, and audiological information in our general patient directory. 7. Individuals Involved in your care
or payment for your care. With
your permission, we may release clinical information about you
to a friend, relative, family member or any other person you identify
who is involved in your clinical care. We
may also give information to someone who helps pay for your care. In addition, we may disclose clinical information
about you to an entity assisting in a disaster/crisis relief effort
so that your family can be notified about your condition, status,
and location. 8. Required by law. We may disclose clinical information about
you when required to do so by federal, state, or local law. 9. Public health. As required by law, we may disclose your health
information to public health authorities for purposes related to: preventing or controlling disease, injury or
disability; reporting child abuse or neglect; reporting domestic
violence; reporting to the Food and Drug Administration problems
with products and reactions to medications; and reporting disease
or infection exposure. We may disclose clinical information to your
employer if the employer requires the healthcare services to determine
whether you suffered a work-related injury. 10. Health oversight activities. We may disclose your health information to
health agencies during the course of audits, investigations, inspections,
licensure and other proceedings. These
activities are necessary for the government to monitor the health
care system, government programs, and compliance with civil rights
laws. 11. Judicial and administrative proceedings. We
may disclose your health information in the course of any administrative
or judicial proceeding. This includes information about you in response
to a court order, subpoena, discovery request, or other lawful processes
by someone else involved in the dispute. 12. Law enforcement. We may disclose your health information to
a law enforcement official for purposes such as identifying or locating
a suspect, fugitive, material witness or missing person, complying
with a court order or subpoena and other law enforcement purposes,
including criminal conduct occurring at Southeastern Hearing Services,
Inc. 13. Deceased person information. We may disclose your health information to
coroners, medical examiners and funeral directors. This may be necessary, for example, to identify
a deceased person, determine the cause of death, or perform other
legal duties. 14. Organ donation. We may disclose your health information to
organizations involved in procuring, banking or transplanting organs
and tissues. 15. Research. We may disclose your health information to
researchers conducting research that has been approved by an Institutional
Review Board or Southeastern Hearing Services’ privacy board. When a retrospective record review is conducted,
no patient contact occurs and privacy of health information will
be de-identified. 16. Public safety. We may disclose your health information to
appropriate persons in order to prevent or lessen a serious and imminent
threat to the health or safety of a particular person or the general
public. 17. Specialized government functions. We may disclose your health information for
military, national security, prisoner and government benefits (limited
to health plans only) purposes. 18. Worker’s compensation. We may disclose your health information as
necessary to comply with worker’s compensation laws. 19. Certain Marketing Activities. We may contact you to provide appointment reminders
or to give you information about other treatments or health-related
benefits and services that may be of interest to you. This may include promotional gifts or treatment
alternatives. 20. Change of Ownership. In the event that Southeastern Hearing Services,
Inc. is sold or merged with another organization, your health information/record
will become the property of the new owner. II. When Southeastern
Hearing Services, Inc. May Not Use or Disclose Your Health Information Except as described
in this Notice of Privacy Practices, Southeastern Hearing Services,
Inc. will not use or disclose your health information without your
written authorization. If
you do authorize Southeastern Hearing Services, Inc. to use or disclose
your health information for another purpose, you may revoke your
authorization in writing at any time. III. Your Health
Information Rights You have the following
rights regarding clinical information we maintain about you: 1. You have the right to request restrictions
or limitations on certain uses and disclosures of your health information. Southeastern
Hearing Services, Inc. is not required to agree to the restriction
that you requested. If we do agree, we will comply with your request
unless the information is needed to provide you emergency treatment. You
must make your request in writing explaining the restrictions and
to whom the limits apply. 2. You have the right to receive your health
information through a reasonable alternative means or at an alternative
location, for example, confidential communications in a certain location. For example, you can ask that we only contact
you at work or by mail. 3. You have the right to inspect and copy
your health information. Usually
this includes clinical and billing records. To
inspect and copy clinical information you must submit your request
in writing to the Privacy Officer. You
may be charged a fee for copying and mailing and any other supplies
associates with your request. We
may deny your request to inspect and copy in very limited circumstances. If you are denied access to clinical information,
you may request that the denial be reviewed. The person conducting the review will not be
the person who denied your request. We
will comply with the outcome of the review. 4. You have a right to request that Southeastern
Hearing Services, Inc. amend your health information that is incorrect
or incomplete. Southeastern
Hearing Services, Inc. is not required to change your health information
and will provide you with information about the denial. We
may deny your request for amendment if the information was not created
by us, not part of the clinical information we keep, not part of
the information you are permitted to inspect and copy, or is accurate
and complete. 5. You have a right to receive an accounting
of health information disclosures except disclosures that Southeastern
Hearing Services, Inc. does not have to account for as described
in parts 1 (treatment), 2 (payment), 3 (health care operations),
4 (information provided to you), 5 (directory listings) and 17 (specialized
government functions) of section I of this Notice of Privacy Practices. 6. You have a right to a paper copy of this
Notice of Privacy Practices. If you would like to
have a more detailed explanation of these rights or if you would
like to exercise one or more of these rights, contact Dr. Keith Ergle at
Southeastern Hearing Services. This
notice can also be found at our website www.forhearing.com. 7. You have the right to revoke your authorization
to use or disclose your clinical information except to the extent
that action has already been taken in reliance on your authorization. IV. Changes to
this Notice of Privacy Practices Southeastern
Hearing Services, Inc. reserves the right to change this Notice of
Privacy Practices. We reserve the right to revise or change the
notice effective for clinical 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 Southeastern Hearing
Services, Inc. facility and on our website www.forhearing.com. V. Complaints If you have questions
or would like additional information, you may contact Southeastern
Hearing Services’ Privacy Officer, 2308-B 6th St, If you believe your
privacy rights have been violated and you would like to file a complaint,
please contact Dr. Keith Ergle, privacy
officer for Southeastern Hearing Services. All
complaints must be submitted in writing. You
will not be penalized or retaliated against for filing a complaint. If you are not satisfied
with the manner in which this office handles a complaint, you may
submit a formal complaint to: Department of
Health and Human Services You may also address
your compliant to one of the regional Offices for Civil Rights. A list of these offices can be found online
at http://www.hhs.gov/ocr/regmail.html.
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