This notice describes how health information about you may be used, disclosed and accessed by you.

Please review it carefully.

If you have questions or concerns, please call us at (434) 793-8255.

1. Purpose

We understand that health information about you is personal. We are committed to protecting that information. We create a record of the care and services you receive at Danville Speech and Hearing Center in order to provide you with quality care and to comply with legal and insurance requirements.

This Privacy Practices statement describes how we use and disclose health information about you, including demographic information, that may identify you and/or your related health care services to carry out your treatment, obtain payment for our services, to perform the daily operations of this practice and for other purposes permitted or required by law. This statement also describes your right to access/control your medical information.

Law requires us to abide by the terms of this statement. We are required to notify affected individuals following a breach of unsecured protected health information.

2. Acknowledgement

You are asked to sign an accompanying statement acknowledging that you have received a copy of our Privacy Practices which serves to create a record that you received a copy of this statement.

3. Changes to this Statement

We may change the terms of our Privacy Practices at any time. Any changes will be effective for all health information that we maintain at that time. Upon your request, we will provide you with any revised Privacy Practices Statement. To request a copy, you may call our office or ask for one at the time of your appointment.

4. Uses and Disclosures of Health Information

Danville Speech and Hearing Center uses and discloses health information about you for:

A. Treatment: We may use your health information for treatment or disclose it to a dentist, physician or other health care or educational provider providing treatment to you.

B. Payment: We may use and disclose your health information to obtain payment for services we provide to you. We may also disclose your health information to another entity that is subject to the Federal Privacy Rules for its payment activities.

C. Health Care Operations: We may use and disclose your health information for our health care operations including quality assessment/improvement activities, reviewing the competence or qualifications of professionals, evaluating practitioner/provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities. We may disclose your health information to another health care provider/organization that is subject to privacy rules and that has a relationship with you to support some of their care operations. We may disclose your information to help these organizations conduct quality assessment/improvement activities, review the competence or qualifications of health care professionals, or detect/prevent fraud and abuse.

D. Appointment reminders: We may use or disclose your medical information to contact you to remind of your appointment, by mail or telephone. Our message will include the name of our practice or the name of our physician as well as the date and time for your appointment or a reminder that an appointment needs to be scheduled.

E. Treatment Alternatives: We may use or disclose your medical information to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. For example, we may contact several home health agencies or physical therapy providers to discuss the services they provide when we have a patient who needs these services.

F. Business Associates: We will share your medical information with third party “business associates” that perform various activities (e.g. billing) for the practice. Whenever an arrangement between our office and business associate involves the use or disclosure of your medical information, we will have a written agreement that contains terms that will protect the privacy of your medical information. For example, we may hire a billing company to submit claims to your health care insurer. Your medical information will be disclosed to the billing company, but a written agreement between our office and the billing company will prohibit the billing company from using your medical information in any other way than what we allow.

G. Others Involved in Your Health Care: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your medical information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional 2 judgment. We may use or disclose your medical information to notify a family member or any other person that is responsible for your care of your location and general health condition. Finally, we may use or disclose your medical information to an authorized public or private entity to assist in (1) disaster relief efforts and (2) to coordinate uses and disclosures to family or other individuals involved in your health care.

H. As Required by Law: We may use or disclose your medical information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures.

I. For Abuse or Neglect: We may disclose your medical information to a public health authority that is authorized by law to receive reports of child or adult abuse or neglect. In addition, we may disclose your medical information if we believe that you have been a victim of abuse, neglect or domestic violence as may be required or permitted by Virginia and/or federal law.

J. For Health Oversight: We may disclose your medical information to a health oversight agency for activities authorized by law. Oversight agencies seeking this information include government agencies that oversee the health system, government benefit programs (such as Medicare or Medicaid), other government regulatory programs and civil rights laws.

K. In Legal Proceedings: We may disclose your medical information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), and in certain conditions in response to a subpoena or other lawful request.

L. For Worker’s Compensation: Your medical information may be disclosed by us as authorized to comply with worker’s compensation laws and other similar legally established programs.

M. For Required Uses and Disclosures: Under the law, we must make disclosures to you and, when required by the Secretary of the Department of Health and Human Services, to investigate or determine our compliance with the requirements of the Health Insurance Portability and Accountability Act and its regulations.

You may give us written authorization to use your health information or 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 uses or disclosures permitted by your authorization while it was in effect. Unless you give us written authorization, we cannot use or disclose your health information for any reason except those described in this statement.

5. Patient Rights

Access: You have the right to look at or get 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 practicably do so.

You must make a second request in writing to obtain access to your health information. You may request access by sending us a letter to the address at the end of this notice. If you request copies, we will charge you a reasonable cost-based fee that may include labor, copying costs, and postage. 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 may – but are not required to – 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 more information about fees.

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your information over the last 6 years (but not before April 14, 2003). That list will not include disclosures for treatment, payment, health care operations, as authorized by you, and for certain other activities. 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. Contact us using the information listed at the end of this notice for more information about fees.

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). Any agreement we may make to a request for additional restrictions must be in writing signed by a person authorized to make such an agreement on our behalf. Your request is not binding unless our agreement is in writing.

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. You must specify in your request the alternative means or location, and provide satisfactory explanation how you will handle payment 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 we should amend the information. We may deny your request under certain circumstances.

6. Complaints

If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

7. Contact

Questions about this statement or should you need more information, please contact us at (434) 793-8255 or at 742 Wilson Street (P.O. Box 1687) Danville, Virginia 24543. A member of our team is available during normal business hours to discuss your privacy questions, concerns, or complaints.