You may request a copy of our
Notice at any time. For more information about our privacy practices,
or for additional copies of this Notice, please contact us using
the information listed at the end of this Notice.
Treatment: We may use
or disclose your health information to a physician or other healthcare
provider providing treatment to you.
Payment: We may use and
disclose your health information to obtain payment for services
we provide to you.
Healthcare Operations: We
may use and disclose your health information in connection with
our healthcare operations. Healthcare operations include
quality assessment and improvement activities, reviewing
the competence or qualifications of healthcare professionals,
evaluating practitioner and provider performance, conducting
training programs, accreditation, certification, licensing
or credentialing activities.
Your Authorization: In
addition to our use of your health information for treatment, payment
or healthcare operations, you may give us written authorization
to use your health information or to disclose it to anyone
for any purpose. If you give us an authorization, you may
revoke it in writing at any time. Your revocation will not
affect any use or disclosures permitted by your authorization
while it was in effect. Unless you give us a written authorization,
we cannot use or disclose your health information for any
reason except those described in this Notice.
To Your Family and Friends: We
must disclose your health information to you, as described in
the Patient Rights section of this Notice. We may disclose
your health information to a family member, friend or other
person to the extent necessary to help with your healthcare
or with payment for your healthcare, but only if you agree
that we may do so.
Persons Involved In Care: We
may use or disclose health information to notify, or assist
in the notification of (including identifying or locating)
a family member, your personal representative or another
person responsible for your care, of your location, your
general condition, or death. If you are present, then prior
to use or disclosure of your health information, we will
provide you with an opportunity to object to such uses
or disclosures. In the event of your incapacity or emergency
circumstances, we will disclose health information based
on a determination using our professional judgment disclosing
only health information that is directly relevant to the
person's involvement in your healthcare. We will also use
our professional judgment and our experience with common
practice to make reasonable inferences of your best interest
in allowing a person to pick up filled prescriptions, medical
supplies, x-rays, or other similar forms of health information.
Marketing Health-Related
Services: We will not use your health information for
marketing communications without your written authorization.
Required by Law: We
may use or disclose your health information when we are
required to do so by law.
Abuse or Neglect: We
may disclose your health information to appropriate authorities
if we reasonably believe that you are a possible victim
of abuse, neglect, or domestic violence or the possible
victim of other crimes. We may disclose your health
information to the extent necessary to avert a serious threat
to your health or safety or the health or safety of others.
National Security: We
may disclose to military authorities the health information
of Armed Forces personnel under certain circumstances.
We may disclose to authorized federal officials health
information required for lawful intelligence, counterintelligence,
and other national security activities. We may disclose
to correctional institutions or law enforcement officials
having lawful custody of protected health information
of inmate or patient under certain circumstances.
Appointment Reminders: We
may use or disclose your health information to provide
you with appointment reminders (such as voicemail
messages, postcards, or letters).
PATIENT RIGHTS
Access: You have the right to review or
obtain copies of your health information, with
limited exceptions. You may request that we provide
copies in a format other than photocopies. We will
use the format you request unless we cannot reasonably
do so. You must make a request in writing to obtain
access to your health information. You may obtain
a form to request access by using the contact information
listed at the end of this Notice. We will charge
you a reasonable cost-based fee for expenses such
as copies and staff time. Illinois law prohibits
charges that exceed the following: $20.48 handling
fee plus 77 cents each for pages 1-25, 51 cents
each for pages 26-50, and 26 cents each for pages
51 to end; plus actual expenses related to the
copying of x-rays, CAT scans, and similar. The
Ohio Ear Institute, LLC limits charges for
records to the amounts allowed under Illinois law.
If you request an alternative format, we will charge
a cost-based fee for providing your health information
in that format. If you prefer, we will prepare
a summary or an explanation of your health information
for a fee. Contact us using the information listed
at the end of this Notice for a full explanation
of our fee structure.
Disclosure Accounting: You
have the right to receive a list of instances in
which we or our business associates disclosed
your health information for purposes, other than treatment,
payment, healthcare operations and certain other
activities, for the last 6 years, but not before
September 1st, 2006. If you request this accounting
more than once in a 12-month period, we may charge
you a reasonable, cost-based fee for responding
to these additional requests.
Restriction: You
have the right to request that we place additional
restrictions on our use or disclosure of
your health information. We are not required to agree
to these additional restrictions, but if we
do, we will abide by our agreement (except in an
emergency).
Alternative Communication: You
have the right to request that we communicate
with you about your health information by
alternative means or to alternative locations. (You must
make your request in writing.) Your request
must specify the alternative means or location,
and provide satisfactory explanation how
payments will be handled under the alternative means
or location you request.
Amendment: You
have the right to request that we amend
your health information. (Your request
must be in writing, and it must explain why the
information should be amended.) We may
deny your request under certain circumstances.
Electronic Notice: If
you receive this Notice on our Web site
or by electronic mail (e-mail), you are entitled
to receive this Notice in written form.
QUESTIONS AND COMPLAINTS
If you want more information about our
privacy practices or have questions or
concerns, please contact us.The practice
allows all patients and their agents to
file complaints with the practice and with
the Secretary of the federal Department
of Health and Human Services (DHHS). A patient
or his or her agent may file a complaint with the
practice whenever he or she believes that the practice
has violated their privacy rights.Complaints to
the practice must be in writing, must describe
the acts or omissions that are the subject of the
complaint, and must be filed within 180 days of
the time the patient became aware or should have
become aware of the violation. Complaints must
be addressed to the attention of the practice's
privacy officer at the practice's address. The
practice investigates each complaint and may, at
its discretion, reply to the patient or the patient's
agent.Complaints to the Secretary of the Department
of Health and Human Services must be in writing,
must name the practice, must describe the acts or omissions
that are the subject of the complaint, and must be filed
within 180 days of the time the patient became aware or
should have become aware of the violation. Complaints must
be addressed to: Office for Civil Rights, U.S. Department
of Health and Human Services, 233 N. Michigan Ave., Suite 240,
Chicago, Ill. 60601, Voice Phone (312) 886-2359, FAX (312)
886-1807, TDD (312) 353-5693.We support your right to the
privacy of your health information. We will not retaliate
in any way if you choose to file a complaint with us or
with the U.S. Department of Health and Hyman Services:
Ohio Ear Institute, LLC Privacy Contact Officer
450 Alkyre Run Dr., Suite 300
Westerville, OH 43082
Telephone Voice/TDD: (614) 839-9173
Fax: (614) 839-9174
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