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NOTICE OF
PRIVACY PRACTICES 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'S LEGAL DUTIES 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. HOW JIRA MAY USE AND DISCLOSE YOUR HEALTH INFORMATION. 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. YOUR RIGHTS TO YOUR HEALTH INFORMATION. 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. COMPLAINTS 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, Effective Date: 07-02-2004 |
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