Effective date: April 14, 2003
Graham Hearing Services, Inc.
Privacy Notice
This document describes the type of information Graham Hearing Services, Inc.
(GHS) gathers about you, with whom that information may be shared, and the
safeguards we have in place to protect it. You have the right to the
confidentiality of your medical information and the right to approve or refuse
the release of specific information except when the release is required by law.
If the practices described in this notice meet your expectations, there is
nothing you need to do. If you prefer that we not share information, we may
honor your written request in certain circumstances described below. If you have
any questions regarding this Privacy Notice, please contact our Privacy Officer,
Jerry Richards, at 479-783-5250.
How We May Use and Disclose Medical Information About You
The following categories describe different ways that we use and disclose
medical information. For each category of uses or disclosures we will explain
what we mean and try to give some examples. Not every use or disclosure in a
category will be listed. However, all of the ways we are permitted to use and
disclose information will fall within one of the categories.
1. For Treatment. We may use medical information about you to provide you
with medical treatment or services. We also may disclose medical information
about you to people outside the facility who may be involved in your medical
care after you leave the facility, such as family members, clergy, or others we
use to provide services that are part of your care.
2. For Payment. We may use and disclose medical information about you so
that the treatment and services you receive at the facility may be billed to and
payment may be collected from you, an insurance company, or a third party. We
may also tell your health plan about a treatment you are going to receive to
obtain prior approval or to determine whether your plan will cover the
treatment.
3. For Health Care Operations. We may use and disclose medical information
about you for facility operations. These uses and disclosures are necessary to
run the facility and make sure that all of our patients receive quality care.
For example, we may use medical information to review our treatment and services
and to evaluate the performance of our staff in caring for you. We may also
combine medical information about many facility patients to decide what
additional services the facility should offer, what services are not needed, and
whether certain new treatments are effective. We may also disclose information
to hearing health care professionals, and other facility personnel for review
and learning purposes. We may also combine the medical information we have with
medical information from other facilities to compare how we are doing and see
where we can make improvements in the care and services that we offer. We may
remove information that identifies you from this set of medical information so
others may use it to study hearing health care and hearing health care delivery
without learning the names of specific patients.
4. Other Permitted and Required Uses and Disclosures will be made only
with your consent, authorization or opportunity to object unless required by
law.
5. You may revoke this authorization , at any time, in writing, except to
the extent that your physician or the physician's practice has taken an action
in reliance on the use or disclosure indicated in the authorization.
Your Rights Regarding Medical Information About You
You have the following rights regarding medical information we maintain about
you:
1. Right to Inspect and Copy. You have the right to inspect and copy
medical information that may be used to make decisions about your care. Usually,
this includes medical and billing records, but does not include psychotherapy
notes.
2. To inspect and copy medical information that may be used to make
decisions about you, you must submit your request in writing to Graham Hearing
Services, Inc., 1005 Lexington Avenue, Fort Smith, AR 72901, If you request a
copy of the information, we may charge a fee for the costs of copying, mailing,
or other supplies associated with your request.
3. We may deny your request to inspect and copy in certain very limited
circumstances. If you are denied access to medical information, you may request
that the denial be reviewed. Another licensed health care professional chosen by
the facility will review your request and the denial. The person conducting the
review will not be the person who denied your request. We will comply with the
outcome of the review.
4. Right to Amend. If you feel that medical information we have about you
is incorrect or incomplete, you may ask us to amend the information. You have
the right to request an amendment for as long as the information is kept by or
for the facility.
5. Right to an Accounting of Disclosures. You have the right to request an
"accounting of disclosures." This is a list of the disclosures we made of
medical information about you.
6. Right to Request Restrictions. You have the right to request a
restriction or limitation on the medical 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 medical information we disclose about you to someone
who is involved in your care, like a family member or friend. For example, you
could ask that we not use or disclose information about a medical procedure that
you had.
7. Right to a Paper Copy of This Notice. You have the right to a paper
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.
Changes to this Notice
1. We reserve the right to change this notice. We reserve the right to
make the revised or changed notice effective for medical 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 in the facility. The notice will contain on the
first page, in the top right-hand corner, the effective date. In addition, each
time you register at or are admitted to the facility for treatment or health
care services as an inpatient or outpatient, we will offer you a copy of the
current notice in effect.
Complaints
1. If you believe your privacy rights have been violated, you may file a
complaint with GHS or with the Secretary of the Department of Health and Human
Services. To file a complaint with GHS contact Jerry Richards, Graham Hearing
Services, Inc., 1005 Lexington Avenue, Fort Smith, AR 72901. All complaints must
be submitted in writing.
You will not be penalized for filing a complaint.
This notice was published and becomes effective on/or before April 14, 2003.
We are required by law to maintain the privacy of, and provide individuals with,
this notice of our legal duties and privacy practices with respect to protected
health information. If you have any objections to this form, please ask to speak
with our HIPPA Compliance Officer in person or by phone at our main phone
number.
