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This notice describes how health information about you may be used and disclosed (given out) and how you can get access to this information. Please read it carefully.



Please note: Where applicable "you" and "your" may also refer to your child.




The privacy of your health (medical) information is important to Jones Institute for Rehabilitative Audiology, LLC (JIRA). JIRA understands that your health information is personal and we are committed to protecting it. JIRA creates a record of the care and services you receive. This record is needed to provide you with quality care, and to comply with certain legal requirements. This notice will tell you about the ways JIRA may use and disclose (give out) health information about you. It will also describe your rights and certain duties we have regarding the use and disclosure of health information.






JIRA is required by law to protect the privacy of your health information and to provide this Notice about its legal duties and health information practices.? JIRA will comply with this Notice.






JIRA may use and disclose your health information for the following purposes:


*     Treatment: JIRA will use your health information to provide you with health care services or products. With your permission (or permission from your legal representative), JIRA may share certain health information specified by you with your family members, doctors, or others involved in your care, as well as other agencies, entities, or individuals outside JIRA.

*      Payment: JIRA may use and disclose health information about you so that the treatment, services and/or products you receive from JIRA may be billed to and payment may be collected from you, an insurance company, or a third party. If your insurer or health plan requires prior approval or other notice in order to determine whether they will pay for treatment, services, or products, JIRA may disclose your health information to them unless you have asked JIRA not to bill your insurance or plan.

*      Health Care Operations: JIRA may use and disclose information about you within JIRA to

manage and improve JIRA's business. This includes quality assessment activities, licensing and accreditation activities, obtaining legal and accounting services, and business planning and management. Other people and companies who are not employees or affiliates of JIRA may help JIRA to run its business. These people and/or companies are JIRA's ?business associates. JIRA may give them limited access to your health information if they need it to do what JIRA has hired them to do and they agree to safeguard your information.

*      Appointment Reminders: JIRA may use and disclose health information to contact you as a reminder that you have an appointment.

*      Treatment Alternatives: JIRA may use and disclose health information to tell your about or recommend treatment options or alternatives that may be of interest to you.

*      Individuals Involved in Your Care: If you agree, JIRA may give health information about you to a friend or family member involved in your care. JIRA may also give information to someone who helps pay for your care. If you cannot agree because of incapacity or emergency circumstances, JIRA may disclose your health information as necessary if JIRA determines that it is in your best interest, based on professional judgment.? JIRA may disclose information about you to an organization assisting in a disaster relief effort so that your family can be notified about your condition, status and location.

*      Research: JIRA will not use or disclose any health information that identifies you or can be used to identify you for any research purposes unless you agree in writing or JIRA follows state law procedures for attempting to notify you of the research request. If you want to participate in clinical research trials involving treatment, you will be asked to sign additional authorizations, either by JIRA or by the entity or person conducting the research trials(s).

*      Worker's Compensation: JIRA may release health information about you for workers' compensation or similar programs to the extent authorize These programs provide benefits for work-related injuries or illnesses.




In addition to the previously-listed purposes, JIRA may need to use or disclose your health information, and will do so without your authorization, for the following purposes:


*      To the government for public health activities as permitted or required by law to report desease statistics, births and deaths, child or vulnerable adult abuse or neglect, domestic violence, reactions to medications, problems with products, and disease exposures;

*      To a health oversight agency for audits, investigations, inspections, and licensure activities;

*      To prevent a serious and imminent threat to the health or safety of a person or the public, or to help the police apprehend an individual involved in a violent crime which may have seriously harmed someone;

*      To organ procurement organizations to facilitate organ or tissue donation and transplantation, consistent with applicable law;

*      To a law enforcement official in response to a court order, subpoena, warrant, summons or similar process; to identify or locate a suspect, witness, or missing person; to identify a victim of crime if, under certain limited circumstances, JIRA is unable to obtain the victim?s agreement; or in emergency circumstances to report the location and perpetrator of a crime;

*      To a court or party in litigation in response to a valid court or administrative order;

*      To a coroner or funeral director as permitted or required by law to identify a deceased person, determine the cause of death, or otherwise as necessary to carry out their duties;

*      If you are an inmate of a correctional institution, to the institution as necessary for your health and the health and safety of other individuals;

*      For military, national security or lawful intelligence activities; or

*      As otherwise as permitted or required by law.


Use and disclosures of your health information, other than those described above, will be made only with your written authorization. You may withdraw that authorization in writing at any time, but JIRA cannot take back any disclosures already made in reliance on a previous authorization.






You have the following rights regarding the health information JIRA maintains about you:


You have the right:

*      to inspect and request a copy of health information JIRA has or uses that may be used to make decisions about your care (with some exceptions). To inspect and request a copy of health information that may be used to make decisions about you, you must submit your request in writing to JIRA. If you request a copy of the information, JIRA may charge a fee for the costs of copying, mailing or other supplies associated with your request. In some cases, JIRA may deny your request to inspect and copy records. If you are denied access to health information, you may request that the denial be reviewed. Another licensed health care professional chosen by JIRA will review your request and the denial. The person conducting the review will not be the person who denied your request. JIRA will comply with the outcome of the review.

*      to ask that your health information be amended if you feel that a record containing your health information is incorrect or incomplete. The request must be made to JIRA in writing. The request must explain why you think the information is wrong or incomplete. JIRA may deny your request if (among other reasons) the information was not created by JIRA; is not included in your medical, billing, or other records used to make decisions about your care; or is otherwise accurate and complete.

*      to request an Accounting of Disclosures. This is a list of certain disclosures JIRA had made of health information about you. The list does not include all disclosures. For example, it does not include disclosures to you, disclosures for treatment, payment, or health care operations already described, or disclosures made with your written authorization. To request an accounting of disclosures, you must submit your request to JIRA in writing. Your request must state a time period which may not be longer than six years and may not include dates before June 2, 2004 (the date that JIRA began providing services to patients).

Your request should indicate in what form you want the list (for example, on paper or electronically). The first list you request within a 12 month period will be free. For additional lists, JIRA may charge you for the cost of providing the list. JIRA 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.

*     to request a restriction or limitation on the health information JIRA uses or discloses about you for treatment, payment, health care operations, or to assist others? involvement in your care. JIRA is not required to agree to your request. If JIRA does agree, JIRA will comply with your request unless the information is needed to provide you emergency treatment. Requests for restriction(s) must be made in writing. In your request, you must tell JIRA (1) what information you want to limit; (2) whether and how you want to limit use, disclosure or both; and (3) to whom you want the limits to apply.

*     to request Confidential Communications. This can mean that you ask JIRA to communicate health information about you in a certain way or at a certain location. For example, you can ask that JIRA only contact you at work or by mail. To request confidential communications, you must make your request in writing. JIRA will attempt to accommodate all reasonable requests.

*     to a paper copy of this notice. You may ask JIRA to give you a copy of this notice at any time.


JIRA reserves the right to change its health information practices and the terms of this Notice. JIRA reserves the right to make the changed Notice effective for health information it already has about you as well as any information it receives after the change. The Notice will contain an effective date on the first page, in the lower right-hand corner.





If you believe your privacy rights have been violated, you may file a complaint with JIRA. You may also file a complaint with the Secretary of the Department of Health and Human Services, Office of Civil Rights, HIPAA Complaint Division, 7500 Security Blvd., C5-24-04, Baltimore, MD 21244. All complaints must be submitted in writing. You will not be penalized for filing a complaint.



Effective Date: 07-02-2004


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