NOTICE OF PRIVACY PRACTICES

To our patients. This notice describes how health information about you, as a patient of this practice, may be used and disclosed, and how you can get access to your health information. This is required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Our commitment to your privacy

Our practice is dedicated to maintaining the privacy of your health information.

The following circumstances may require us to use or disclose your health information:

1. Treatment: In order to provide you with the health care you require, the practice will provide your health information to those health care professionals, whether on the practice’s staff or not, directly involved in your care so that they may understand your medical condition and needs.

2. Payment: In order to get paid for services provided to you, the practice will provide your health information, directly or through a billing service, to appropriate third party payors, pursuant to their billing and payment requirements.

3. Health Care Operations: In order for the practice to operate in accordance with applicable law and insurance requirements and in order for the practice to continue to provide quality and efficient care, it may be necessary for the Practice to compile, use and/or disclose your health information.

4. To public health authorities and health oversight agencies that are authorized by law to collect information.

5. Lawsuits and similar proceedings in response to a court or administrative order.

6. If required to do so by a law enforcement official.

7. When necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. We will only make disclosures to a person or organization able to help prevent the threat.

8. If you are a member of U.S. or foreign military (including veterans) and if required by the appropriate authorities.

9. To federal officials for intelligence and national security activities authorized by law.

10. To correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official.

11. For Workers Compensation and similar programs.

Your rights regarding your health information

1. Communication: You can request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. We will accommodate reasonable requests.

2. You can request a restriction in our use or disclosure of your health information for treatment, payment, or health care operations. Additionally, you have the right to request that we restrict our disclosure of your health information to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; emergencies, or when the information is necessary to treat you.

3. You have the right to inspect and obtain a copy of the health information that may be used to make decisions about you, including client medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to Hofstra Family Hearing Center.

4. You may ask us to amend your health information if you believe it is incorrect or incomplete, and as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted to Hofstra Family Hearing Center. You must provide us with a reason that supports your request for amendment.

5. Right to a copy of this notice: You are entitled to receive a copy of this Notice of Privacy Practices. You may ask us to give you an additional copy of the Notice at any time. To obtain an additional copy of this notice, contact our front desk receptionist.

6. Right to file a complaint: 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. To file a complaint with our practice, contact Hofstra Family Hearing Center. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

7. Right to provide an authorization for other uses and disclosures: Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law.

If you have any questions regarding this notice or our health information privacy policies, please contact Hofstra Family Hearing Center at (708) 385-9402

I hereby acknowledge that I have been presented with a copy of Hofstra Family Hearing Center’s Notice of Privacy Practices.

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If the client is a minor:

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