Hearing Healthcare That Puts the Patient First

Privacy Policy

Notice of Privacy Practices


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.


ABOUT THIS NOTICE
Adaptive Audiology Solutions PC is committed to protecting your health information. This
Notice of Privacy Practices (“Notice”) is provided pursuant to the Health Insurance Portability
and Accountability Act of 1996 (“HIPAA”) as revised in the 2013 HIPAA Omnibus Rule. This
Notice describes how we may use and disclose your protected health information to carry out
treatment, payment or audiological/health care operations and for other purposes that are
permitted or required by law. This Notice also describes your rights and our duties with respect
to your protected health information.

“Protected health information” is information about you that may identify you and that relates to
your past, present or future physical or mental health/condition and related audiological/health
care services. We must follow the privacy practices that are described in this Notice while it is in
effect. If you have any questions about this Notice, please contact our Privacy Officer, Sue
Schrader, at (712) 775-2625, or [email protected]

HOW WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION

The following categories describe the different ways that we may use and disclose your protected
health information. These examples are not meant to be exhaustive, but to illustrate the types of
uses and disclosures that may be made.

1. Treatment
We may use and disclose your protected health information to provide, coordinate, or manage
your audiological treatment and any related services. We may also disclose your protected health
information to other third party providers involved in your audiological/health care. For example,
your protected health information may be provided to a physician or other audiological/health
care provider (e.g. a specialist or laboratory) to whom you have been referred to ensure that the
physician or other audiological/health care provider has the necessary information to diagnose or
treat you.

2. Payment
We may use and disclose your protected health information so that the treatment and health care
services you receive may be billed to you, your insurance company, a government program, or
third party payors. This may include certain activities that your health insurance plan may
undertake before it approves or pays for the audiological/health care services we recommend for
you, such as making a determination of eligibility or coverage for insurance benefits, reviewing
services provided to you for medical necessity, and undertaking utilization review activities. For
example, we may provide your health plan with medical information about the
audiological/health care services Adaptive Audiology Solutions PC rendered to you for
reimbursement purposes.

3. Audiological/Health Care Operations
We may use and disclose your protected health information for audiological/health care
operation purposes. These uses and disclosures are necessary to make sure that all of our patients
receive quality care and for our operation and management purposes. For example, we may use
your protected health information to review the quality of the treatment and services you receive
and to evaluate the performance of our team members in caring for you. We also may disclose
information to audiologists, physicians, nurses, technicians, medical students, and other
personnel for educational and learning purposes.

4. Treatment Communications
We may provide treatment communications concerning treatment alternatives or other health
related products or services. For communications for which we or a business associate may
receive financial remuneration in exchange for making the communication, we must obtain
written authorization unless the communication is made face-to-face and/or involving
promotional gifts of nominal value. If you do not wish to receive these communications please
submit a written request to our Privacy Officer, Sue Schrader, Adaptive Audiology Solutions PC,
409 W. 7th St., Carroll, Iowa 51401.

5. Fundraising Activities
We may use or disclose your demographic information and dates of services provided to you, as
necessary, in order to contact you for fundraising activities supported by Adaptive Audiology
Solutions PC You have the right to opt out of receiving fundraising communications. If you do
not want to receive these materials, please submit a written request to our Privacy Officer, Sue
Schrader, Adaptive Audiology Solutions PC, 409 W. 7th St., Carroll, Iowa 51401.

6. Others Involved in Your Healthcare
Unless you object, we may disclose to a member of your family, a relative, a close friend or any
other person you identify, your protected health 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 judgment. Also, for example, if you are brought into this office and are unable
to communicate normally with your clinician for some reason, we may find it is in your best
interest to give your hearing instrument and other supplies to the friend or relative who brought
you in for treatment. We may also use and disclose protected health information to notify such
persons of your location, general condition, or death. We also may coordinate with disaster relief
agencies to make this type of notification. We also may use professional judgment and our
experience with common practice to make reasonable decisions about your best interests in
allowing a person to act on your behalf to pick up your hearing instruments, supplies, records, or
other things that contain protected health information about you.

7. Required by Law
We may use or disclose your protected health 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.

8. Public Health
We may disclose your protected health information for public health activities and purposes to a
public health authority that is permitted by law to collect or receive the information. The
disclosure will be made for the purpose of controlling disease, injury or disability. We may also
disclose your protected health information, if directed by the public health authority, to a foreign
government agency that is collaborating with the public health authority.

9. Business Associates
We may disclose your protected health information to our business associates that perform
functions on our behalf or provide us with services if the information is necessary for such
functions or services. To protect your health information, however, we require the business
associate to appropriately safeguard your information.

10. Communicable Diseases
We may disclose your protected health information, if authorized by law, to a person who may
have been exposed to a communicable disease or may otherwise be at risk of contracting or
spreading the disease or condition.

11. Health Oversight
We may disclose your protected health information to a health oversight agency for activities
authorized by law, such as audits, investigations, and inspections. Oversight agencies
seeking this information include government agencies that oversee the audiological/health care
system, government benefit programs, other government regulatory programs and civil rights
laws.

12. Abuse or Neglect
We may disclose your protected health information to a public health authority that is authorized
by law to receive reports of abuse or neglect. In addition, we may disclose your protected health
information if we believe that you have been a victim of abuse, neglect or domestic violence to
the governmental entity or agency authorized to receive such information. In this case, the
disclosure will be made consistent with the requirements of applicable federal and state laws.

13. Food and Drug Administration
We may disclose your protected health information to a person or company required by the Food
and Drug Administration to report adverse events, product defects or problems, biologic product
deviations, track products to enable product recalls, to make repairs or replacements, or to
conduct post marketing surveillance, as required by law.

14. Legal Proceedings
We may disclose your protected health 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,
discovery request or other lawful process.

15. Law Enforcement
We may disclose your protected health information, so long as applicable legal requirements are
met, for law enforcement purposes.

16. Coroners, Funeral Directors, and Organ Donation
We may disclose your protected health information to a coroner or medical examiner for
identification purposes, determining cause of death or for the coroner or medical examiner to
perform other duties authorized by law. We may also disclose your protected health information
to a funeral director, as authorized by law, in order to permit the funeral director to carry out its
duties. We may disclose such information in reasonable anticipation of death. Protected health
information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.

17. Research
We may disclose your protected health information to researchers when their research has been
approved by an institutional review board that has reviewed the research proposal and
established protocols to ensure the privacy of your protected health information.

18. Serious Threat to Health or Safety
Consistent with applicable federal and state laws, we may disclose your protected health
information to prevent or lessen a serious threat to your health and safety or to the health and
safety of another person or the public.

19. Military Activity and National Security
If you are involved with military, national security or intelligence activities or if you are in law
enforcement custody, we may disclose your protected health information to authorized officials
so they may carry out their legal duties under the law.

20. Workers’ Compensation
We may disclose your protected health information as authorized for workers’ compensation or
other similar programs that provide benefits for a work-related illness.

21. For Data Breach Notification Purposes
We may use or disclose your protected health information to provide legally required notices of
unauthorized access to or disclosure of your health information.

22. Required Uses and Disclosures
Under the law, we must make disclosures to you and when required by the Secretary of the
U.S. Department of Health and Human Services to investigate or determine our compliance with
the requirements of Section 164.500 et. Seq.

SPECIAL PROTECTIONS FOR HIV, ALCOHOL AND SUBSTANCE ABUSE,
MENTAL HEALTH AND GENETIC INFORMATION
Certain federal and state laws may require special privacy protections that restrict the use and
disclosure of certain health information, including HIV-related information, alcohol and
substance abuse information, mental health information, and genetic information. Some parts of
this Notice may not apply to these types of information.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION BASED
UPON YOUR WRITTEN AUTHORIZATION

The following uses and disclosures will be made only with your written authorization:
1. Uses and disclosures of protected health information for marketing purposes for which we or a
business associate may receive remuneration; and

2. Disclosures that constitute a sale of protected health information.
Other uses and disclosures of your protected health information not described in this Notice will
be made only with your written authorization, unless otherwise permitted or required by law.
You may revoke this authorization, at any time, in writing, except to the extent that Adaptive
Audiology Solutions PC has taken an action in reliance on the use or disclosure indicated in the
authorization. Additionally, if a use or disclosure of protected health information described
above in this Notice is prohibited or materially limited by other laws that apply to use, it is our
intent to meet the requirements of the more stringent law.

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION
The following is a statement of your rights with respect to your protected health information and
a brief description of how you may exercise these rights.

1. Right to be Notified if there is a Breach of Your Protected Health information
You have the right to be notified upon a breach of any of your unsecured protected health
information.

2. Right to Inspect and Copy
You may inspect and obtain a copy of your protected health information that is contained in your
medical and billing records and any other records that Adaptive Audiology Solutions PC uses for
making decisions about you. To inspect and copy your medical information, you must submit a
written request to our Privacy Officer, Sue Schrader, Adaptive Audiology Solutions PC, 409 W.
7th St., Carroll, Iowa 51401. If you request a copy of your information, we may charge you a
reasonable fee for the costs of copying, mailing or other costs incurred by us in complying with
you request. Under federal law, you may not inspect or copy the following records:
psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil,
criminal, or administrative action or proceeding; and protected health information that is subject
to law that prohibits access to protected health information. Depending on the circumstances, we
may deny your request to inspect and/or copy your protected health information. A decision to
deny access may be reviewable. Please contact our Privacy Officer, Sue Schrader, at (712) 775-
2625, or [email protected] if you have questions about access to your medical
record.

3. Right to Request Restrictions
You may ask us not to use or disclose any part of your protected health information for the
purposes of treatment, payment or healthcare operations. You may also request that any part of
your protected health information not be disclosed to family members or friends who may be
involved in your care or for notification purposes as described in this Notice. To request a
restriction on who may have access to your protected health information, you must submit a
written request to our Privacy Officer, Sue Schrader, Adaptive Audiology Solutions PC, 409 W.
7th St., Carroll, Iowa 51401. Your request must state the specific restriction requested and to
whom you want the restriction to apply. Adaptive Audiology Solutions PC is not required to
agree to a restriction that you may request, unless you are asking us to restrict the use and
disclosure of your protected health information to a health plan for payment or
audiological/health care operation purposes and such information you wish to restrict pertains
solely to a audiological/health care item or service for which you have paid us “out-of-pocket” in
full. If we believe it is in your best interest to permit the use and disclosure of your protected
health information, your protected health information will not be restricted. If we do agree to the
requested restriction, we may not use or disclose your protected health information in violation
of that restriction unless it is needed to provide emergency treatment.

4. Right to Request Confidential Communication
You have the right to request to receive confidential communications from us by alternative
means or at an alternative location. We will accommodate reasonable requests. You must request
this by submitting a written request to our Privacy Officer, Sue Schrader, Adaptive Audiology
Solutions PC, 409 W. 7th St., Carroll, Iowa 51401.

5. Right to Request Amendment
You may request an amendment of your protected health information contained in your medical
and billing records and any other records that Adaptive Audiology Solutions PC uses for making
decisions about you, for as long as we maintain the protected health information. You must
request for an amendment by submitting a written request to our Privacy Officer, Sue Schrader,
Adaptive Audiology Solutions PC, 409 W. 7th St., Carroll, Iowa 51401, and provide the
reason(s) that support your request. In certain cases, we may deny your request for an
amendment. If we deny your request for an amendment, you have the right to file a statement of
disagreement with us and we may prepare a rebuttal to your statement and will provide you with
a copy of any such rebuttal.

6. Right to an Accounting of Disclosures
You have the right to receive an accounting of certain disclosures we have made, if any, of your
protected health information. This right applies to disclosures for purposes other than treatment,
payment or healthcare operations as described in this Notice. It excludes disclosures we may
have made to you, for a resident directory, to family members or friends involved in your care, or
for notification purposes. The right to receive this information is subject to certain exceptions,
restrictions and limitations. Additionally, limitations are different for electronic health records.
You must request for an accounting of disclosures by submitting a written request to our Privacy
Officer, Sue Schrader, Adaptive Audiology Solutions PC, 409 W. 7th St., Carroll, Iowa 51401,
and provide the reason(s) that support your request.
 

7. Right to Obtain a Paper Copy of this Notice
You have the right to receive a paper copy of this Notice even if you have agreed to receive this
notice electronically. You may ask us to give you a copy of this notice at any time. To obtain a
paper copy of this Notice, you can contact our Privacy Officer, Sue Schrader, at (712) 775-2625,
or [email protected] You may also obtain a copy of this Notice at
www.adaptiveaudiology.com.
 

COMPLAINTS OR QUESTIONS
If you believe your privacy rights have been violated, you may file a complaint with us or with
the Secretary of the U.S. Department of Health and Human Services. If you have a question
about this Notice or wish to file a complaint with us, please contact our Privacy Officer, Sue
Schrader, at (712) 775-2625, or [email protected] or the Corporate Privacy Officer at
the address listed below. All complaints must be submitted in writing. Adaptive Audiology
Solutions PC will not retaliate against you for filing a complaint.
 

CHANGES TO THIS NOTICE
We reserve the right to change this Notice at any time. The new Notice will be effective for all
health information we already have about you as well as any information we receive in the
future. You can also obtain a revised Notice at www.adaptiveaudiology.com or by contacting our
Privacy Officer, Sue Schrader, Adaptive Audiology Solutions PC, 409 W. 7th St., Carroll, Iowa
51401.
Adaptive Audiology Solutions PC
Attn: Corporate Privacy Officer
 

This Notice is effective as of April 2013