NOTICE OF PRIVACY INFORMATION PRACTICES Effective Date: 9/26/19
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.
A. PURPOSE OF THE NOTICE
MK Larson Audiology is committed to preserving the privacy and confidentiality of your health information, which is created and/ or maintained at our clinic. In the unlikely event that the practice is sold or merges with another organization, your record will become the property of that organization. This medical information may be in paper or electronic format. State and federal laws and regulations require us to implement policies and procedures to safeguard the privacy of your health information and to notify affected parties following a breach of unsecured protected health information.
This Notice will provide you with information regarding our privacy practices and applies to all of your health information created and/or maintained at our clinic, including any information that we receive from other health care providers or facilities. This Notice describes the ways in which we may use or disclose your health information and also describes your rights and our obligations concerning such uses or disclosures. We will abide by the terms of the Notice, including any future revisions that we may make to the Notice as required or authorized by law. We reserve the right to change this Notice and to make the revised or changed Notice effective for health 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, which will identify its effective date, in our clinic and on our website at: www.larsonaudiology.com.
The privacy practices described in this Notice will be followed by:
1. Any health care professional authorized to enter information into your medical record created and/or maintained at our clinic.
2. All employees, student externs and other service providers who have access to your health information at our clinic. The individuals identified above will share your health information with each other for purposes of treatment, payment and health care operations, as further described in the Notice.
B. USES AND DISCLOSURES OF HEALTH INFORMATION FOR TREATMENT,
PAYMENT AND HEALTH CARE OPERATIONS.
1. Treatment, Payment and Health Care Operations. The following section describes different ways that we may use and disclose your health information for purposes of treatment, payment, and health care operations. We explain each of these purposes below and include examples of the types of uses or disclosures that may be made for each purpose. We have not listed every type of use or disclosure, but the ways in which we use or disclose your information will fall under one of these purposes.
(a) Treatment. We may use your health information to provide you with health care treatment and services. We may disclose your health information to doctors, nurses, nursing assistants, medication aides, technicians, medical and nursing students, rehabilitation therapy specialists, or other personnel who are involved in your health care. For example, we may order a radiological exam to confirm an ear, nose or throat diagnosis. We may need to give health information to the radiology firm and the radiologist to help determine the diagnosis. We will also need to share our findings and diagnosis with your referring physician.
(b) Payment. We may use or disclose your health information so that we may bill and receive payment from you,
an insurance company or another third party for the health care services you receive from us or others.
(c) Health Care Operations. We may use or disclose your health information in order to perform the necessary administrative, educational, quality assurance and business functions of our clinic. For example, we may use your health information to evaluate the performance of our staff in caring for you. We also may use your health information to evaluate whether certain treatment, or services offered by our clinic are effective. We may also disclose health information about you to your health plan in order to obtain prior approval for the services we provide to you or to determine that your health plan will pay for the treatment. For example, we may need to give health information to your health plan in order to obtain prior approval to perform a diagnostic test such as a magnetic resonance imaging scan (MRI) or a CT scan, or for performing surgical or office procedures.
C. USES AND DISCLOSURES OF HEALTH INFORMATION IN SPECIAL SITUATIONS.
We may use or disclose your health information in certain special situations, as described below. For these situations, you have the right to limit these uses and disclosures as provided for in Section F of this Notice.
1. Appointment Reminders. We may use or disclose your health information for purposes of contacting you to remind you of a health care appointment. If you are not available, this information may be left on an answering machine or with the person answering your phone.
2. Family Members and Friends. We may disclose your health information to individuals, such as family members and friends, who are involved in your care or who help pay for your care. We may make such disclosures when:
(a) we have your verbal agreement to do so;
(b) we make such disclosures and you do not object;
(c) we can infer from the circumstances that you would not object to such disclosures. For example, if your spouse comes
into the exam room with you, we will assume that you agree to our disclosure of your information while your spouse is present in the room.
D. OTHER PERMITTED OR REQUIRED USES AND DISCLOSURES OF HEALTH INFORMATION.
There are certain instances in which we may be required or permitted by law to use or disclose your health information without your permission.
These instances are as follows:
1. As Required by Law. We may disclose your health information when required by federal, state, or local law to do so. Disclosure can result from statutory requirements such as mandatory reporting of abuse, neglect or domestic violence. Information could also be disclosed to law enforcement or judicial proceedings. These disclosures are always limited to meet only the relevant requirements of the law.
2. Public Health Activities. We may disclose your health information to public health authorities that are authorized by law to receive and collect health information for the purpose of preventing or controlling disease, injury or disability; to report births, deaths, suspected abuse or neglect, reactions to medications; or to facilitate product recalls. If reports of neglect or abuse are to be submitted, the patient would be notified except when in the judgment of the medical staff, the notification would place the patient in additional risk of harm.
3. Health Oversight Activities. We may disclose your health information to a health oversight agency that is authorized by law to conduct health oversight activities, including audits, investigations, inspections, or licensure and certification surveys. These activities are necessary for the government to monitor the persons or organizations that provide health care to individuals and to ensure compliance with applicable state and federal laws and regulations.
4. Judicial or Administrative proceedings. We may disclose your health information to courts or administrative agencies charged with the authority to hear and resolve lawsuits or disputes. We may disclose your health information pursuant to a court order, a subpoena, a discovery request, or other lawful process issued by a judge or other person involved in the dispute, but only if efforts have been made to (i) notify you of the request for disclosure; or if objections have been resolved thru an administrative order.
5. Worker’s Compensation. We may disclose your health information to worker’s compensation programs and insurers when your health condition arises out of a work-related illness or injury.
6. Law Enforcement Official. We may disclose your health information in response to a request received from a law enforcement official to report criminal activity or to respond to a subpoena, court order, warrant, summons, or similar process.
7. Coroners, Medical Examiners, or Funeral Directors. We may disclose your health information to a coroner or medical examiner for the purpose of identifying a deceased individual or to determine the cause of death. We also may disclose your health information to a funeral director for the purpose of carrying out his/her necessary activities.
8. Organ Procurement Organizations or Tissue Banks. If you are an organ donor, we may disclose your health information to organizations that handle organ procurement, transplantation, or tissue banking for the purpose of facilitating organ or tissue donation or transplantation.
9. Research. We may use or disclose your health information for research purposes under certain limited circumstances. Because all research projects are subject to a special approval process, we will not use or disclose your health information for research purposes until the particular research project for which your health information may be used or disclosed has been approved through this special approval process. In most instances, we will ask for your specific permission to use or disclose your health information if the researcher will have access to your name, address or other identifying information.
10. Marketing. As long as we are not compensated for the communication, we may contact you regarding products that may be related to your treatment. We may be compensated for the products or treatments recommended. Your protected health information will not be used for any other marketing purpose without your prior consent.
11. To Avert a Serious Threat to Health or Safety. We may use or disclose your health information when necessary, to prevent a serious threat to the health or safety of you or other individuals.
12. Immunizations to Schools. We may disclose proof of immunization to a school that requires the information before admission to the school can occur. This is done with the agreement of the patient or a parent.
13. Military and Veterans and Incarcerated persons. If you are a member of the armed forces, we may use or disclose your health information as required by military command authorities. We are also required by law to report to correctional institutions and law enforcement officers that have lawful custody.
14. National Security and Intelligence Activities. We may use or disclose your health information to authorized federal officials for purposes of intelligence, counterintelligence, and other national security activities, as authorized by law.
15. Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may use or disclose your health information to the correctional institution or to the law enforcement official as may be necessary (i) for the institution to provide you with health care; (ii) to protect the health or safety of you or another person; or (iii) for the safety and security of the correctional institution.
E. USES AND DISCLOSURES PURSUANT TO YOUR WRITTEN AUTHORIZATION.
Except for the purposes identified above in Sections B through D, we will not use or disclose your health information for any other purposes unless we have your specific written authorization. You have the right to revoke a written authorization at any time as long as you do so in writing. If you revoke your authorization, we will no longer use or disclose your health information for the purposes identified in the authorization, except to the extent that we have already taken some action in reliance upon your authorization. Additional Protections for Psychotherapy Notes, Genetic Test Results, HIV Results or Treatment for Drug or Alcohol Abuse require specific authorization on our consent for release form.
F. YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION.
You have the following rights regarding your health information. You may exercise each of these rights, in writing, by providing us with a completed form that you can obtain from MK Larson Audiology registration areas. In some instances, we may charge you for the cost(s) associated with providing you with the requested information. Additional information regarding how to exercise your rights, and the associated costs, can be obtained from the patient registration areas.
1. Right to Inspect and Copy. You have the right to inspect and copy health information that may be used to make decisions about your care. This may be requested in paper or electronic format. We may deny your request to inspect and copy your health information in certain limited circumstances. If you are denied access to your health information, you may provide additional information and request that the denial is reconsidered.
2. Right to Amend. You have the right to request an amendment of your health information that is maintained by or for our clinic and is used to make health care decisions about you. We may deny your request if it is not properly submitted or does not include a reason to support your request. We may also deny your request if the information sought to be amended:
(a) was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
(b) is not part of the information that is kept by or for our clinic;
(c) is not part of the information that you are permitted to inspect and copy; or
(d) is accurate and complete.
You have the right to dispute a decision to deny your amendment. That written dispute, along with any rebuttal from our office, will be maintained in the record.
3. Right to an Accounting of Disclosures.
You have the right to request an accounting of the disclosures of your health information made by us. This accounting will not include disclosures of health information that we made for purposes of treatment, payment or health care operations, releases pursuant to a written authorization that you have signed or release or releases for reasons listed in sections C & D of this Notice.
4. Right to Request Restrictions. You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the health information we disclose about you to someone, such as a family member or friend, who is involved in your care or in the payment of your care. For example, you could ask that we not use or disclose information regarding a particular treatment that you received. With the exception of privately paid services requested to be released to your insurance company, we are not required to agree to your request. If we do agree, that agreement must be in writing and signed by you and us.
5. Right to Request Confidential Communication. You have the right to request that we communicate with you about your health care in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.
6. Right to a Paper or Electronic Copy of this Notice. You have the right to receive a paper or electronic copy of this Notice. You may ask us to give you a copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice.
7. Right to breach notification. If there is a breach of unsecured protected health information, we will notify you as required by law. This notification may come from us or our business associate.
G. QUESTIONS OR COMPLAINTS.
If you believe your privacy rights have been violated, you may file a complaint with our clinic. To file a complaint with our clinic, contact us at MK Larson Audiology, 628 California Blvd., Building C, Suite D-1, San Luis Obispo, CA 93401. All complaints must be submitted in writing. You will not be penalized for filing a complaint. If you are not satisfied with the manner in which we handle your complaint, you may file the complaint with the Office for Civil Rights.
The Regional office contact information is:
Michael Leoz, Regional Manager
Office for Civil Rights
U.S. Department of Health and Human Services
90 7th Street, Suite 4-100
San Francisco, CA 94103
Customer Response Center: (800) 368-1019
Fax: (202) 619-3818
TDD: (800) 537-7697
The official complaint form for the Office of Civil Rights can be located at: