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Privacy Policy
Speech, Hearing and Rehabilitation Center
Notice of Privacy Practices
This notice describes how medical information about you or the person you
represent may be used and disclosed and how you can get access to this
information. Please review it carefully.
I. Our Duty to Safeguard Your Protected Health Information.
Individually identifiable information about your past, present or future
health or condition, the provision of health care to you, or payment for the
health care is considered "Protected Health Information," (PHI). We are
required to extend certain protections to your PHI, and to give you this
Notice about our privacy practices that explains how, when and why we may
use or disclose your PHI. Except in specified circumstances, we must use or
disclose only the minimum necessary PHI to accomplish the intended purpose
of the use or disclosure.
We are required to follow the privacy practices described in this Notice,
though we reserve the right to change our privacy practices and the terms of
this Notice at any time. If we do so, we will post a new Notice in our Intake
office. You may request a copy of the new notice from our Information Manager,
and it will also be posted on our website at http://acoc.ashtabula.net/shrc.
II. How We May Use and Disclose Your Protected Health Information.
We use and disclose PHI for a variety of reasons. We have a limited right to
use and/or disclose your PHI for purposes of treatment, payment or our health
care operations. For uses beyond that, we must have your written authorization
unless the law permits or requires us to make the use or disclosure without
your authorization. If we disclose your PHI to an outside entity in order
for that entity to perform a function on our behalf, we must have in place
an agreement from the outside entity that it will extend the same degree
of privacy protection to your information that we must apply to your PHI.
However, the law provides that we are permitted to make some uses/disclosures
without your consent or authorization. The following offers more description
and some examples of our potential uses/disclosures of your PHI.
* Uses and Disclosures Relating to Treatment, Payment, or Health Care
Operations. Generally, we may use or disclose your PHI as follows:
For Treatment We may disclose your PHI to doctors, nurses,
therapists teachers, and other professionals who are involved in
providing your care. For example, your PHI may be shared among the
members of our treatment team. This team may include outside entities
or individuals with whom we contract for treatment services or with
whom we cooperate in your treatment. Such outside entities might be
Head Start or the local school district. We may also use or disclose
PHI to hearing aid manufacturers if you are purchasing a hearing aid.
To Obtain Payment We may use/disclose your PHI in order to
bill and collect payment for your health care services. For
examples, we may release portions of your PHI to your insurance
company including private insurance, Medicaid, Medicare, or Ashtabula
County Department of Jobs and Family Services in order to get paid
for the variety of services that we deliver to you.
For Health Care Operations We may use/disclose your PHI in
the course of operating the Speech, Hearing and Rehabilitation
Center. For example, we may use your PHI in evaluating the quality
of our services, or we may disclose certain portions of your PHI to
an accountant for audit purposes. We may release portions of your
PHI to the Ashtabula County Health Department for children referred
to us from their Well Child Clinic. In any case, we require these
persons or entities to appropriately safeguard the privacy of your
information.
Appointment Reminders or Messages During Treatment Unless you
provide us with alternative instructions, we may leave brief messages
on your answering machine, with someone you have designated when you
have no phone, or through the mail.
* Uses and Disclosures Requiring Authorization: For Uses and
Disclosures Beyond Treatment, Payment and Operations Purposes
we are required to have your written authorization unless the use
or disclosure falls within one of the exceptions listed below.
Authorizations can be revoked at any time to stop future
uses/disclosures except to the extent that we have already
undertaken an action in reliance upon your authorization.
* Uses and Disclosures of PHI Not Requiring Consent or Authorization:
The law provides that we may use/disclose your PHI without your
consent or authorization in the following circumstances:
1. When required by law
2. To report suspected child abuse or neglect as required by
law. We may also disclose PHI when we believe you to be a
victim of domestic violence.
3. For public health activities We may disclose PHI when we
are required to collect information about disease or
injury or to cooperate with a public health investigation.
4. To cooperate with government oversight agencies which may
be conducting audits, investigations or civil or criminal
proceedings.
5. To your employer if we have provided a test at your
employer's request.
6. When required to do so by a court or administrative order,
subpoena or discovery request; in most cases you will have
notices of such release.
7. When necessary to report to the Food and Drug
Administration adverse events, product defects, or to
participate in product recalls.
8. To workers' compensation agencies if necessary for your
workers' compensation benefit determination.
9. To the Department of Veterans Affairs for purposes of
determining your eligibility for benefits.
10. To a correctional facility having custody of an inmate.
III. Your Rights Regarding Your Protected Health Information
You have the following rights relating to your PHI:
* To Request Restrictions On Uses/Disclosures: You have the right
to ask that we limit how we use or disclose your PHI. We will
consider your request, but are not legally bound to agree to the
restriction. To the extent that we do agree to any restrictions
on our use/disclosure of your PHI, we will put the agreement in
writing and abide by it except in emergency Situations. We cannot
agree to limit uses/disclosures that are required by law.
* To Choose How We Contact You: You have the right to ask that we
send you information at an alternative address or by an alternative
means. We must agree to your request as long as it is reasonably
easy for us to do so.
* To Inspect and Copy Your PHI: Unless your access is restricted for
clear and documented reason, you have a right to see your PHI upon
your written request. We will respond to your request within 30
days. If we deny your access, we will give you written reasons for
the denial and explain any right to have the denial reviewed. If you
want copies of your PHI, a charge for copying may be imposed,
depending on your circumstances. You have a right to choose what
portions of your information you want copied and to have prior
information on the cost of copying.
* To Request Amendment of Your PHI: If you believe that there is
a mistake or missing information in our record of your PHI, you
may request, in writing, that we correct or add to the record.
The reason for the request must be included. We will respond
within 60 days of receiving your request. We are not required
to make all requested amendments, but we will give careful
consideration to each request. We may deny the request if we
determine that the PHI is: (i) correct and complete or (ii) not
created by us and/or not part of our records. If we deny your
request we will notify you in writing as to the reason for the
denial and of your right to have the request and the denial
appended to your PHI. If we approve your request, we will amend
your PHI and inform you and also inform others that need to know
about the change to your PHI.
* To Find Out What Disclosures Have Been Made: You have a right
to receive an accounting of certain disclosure made by us of your
personal health information after April 14, 2003. Such an accounting
does not include disclosures for treatment, payment or operations;
disclosures made to you or your representative; or disclosures made
pursuant to your written authorization; The list will also not
include any disclosures made for national security purposes, to law
enforcement officials or correctional facilities, or disclosures
made before April 14, 2003. We will respond to your written request
within 60 days of receiving it. Accounting Request forms are
available from the Information Manager
* To Receive This Notice: You will be asked to sign an
acknowledgment form that you received this Notice of Privacy
Practices.
* To File a Complaint: If you believe that your privacy rights
have been violated, you can file a written complaint with the
Executive Director. You may also file a complaint with the Secretary
of the U. S. Department of Health and Human Services in Washington
D.C. in writing within 180 days of a violation of your privacy
rights. There will be no retaliation for filing a complaint.
IV. Who May Exercise Patient Rights
* An adult patient
* The guardian of an adult patient
* The patient's representative if that person has been given
written authorization to act on his behalf
* Parents or legal guardians
* Divorced parents: Both have equal right to authorize
uses and disclosures of a child's PHI and to exercise
patient rights on behalf of the minor. No preference
is given to the custodial parent (ORC 3109.10) unless
there is a court order stating otherwise.
If you have questions or need further assistance regarding this Notice, you may
contact the Information Manager in person or by phone at 992-4433.
Effective Date: This notice is effective April 14, 2003
Acknowledgment: I have received a copy of the Notice of Privacy Practices
of the Speech, Hearing and Rehabilitation Center on
__________________________________________
Date
_________________________________
Printed Name of Patient
_________________________________
Printed Name of signer if different from patient
__________________________________
Signature of patient or signer
__________________________________
Signer's relationship to patient
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