Notice of Privacy Practices
This notice described 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
Designer Audiology, LLC 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 Designer Audiology, LLC may use and disclose your protected health
information to carry out treatment, payment or audiologic/health care operations and for other purposes that are
permitted or required by law. This Notice also describes your rights and Designer Audiology, LLC’s 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 audiologic/health care services. Designer Audiology, LLC 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 and/or Owner, Dr. Alicia D.D. Spoor, Owner, at (443) 410-4410 or
Alicia.Spoor@DesignerAudiology.com.
HOW DESIGNER AUDIOLOGY, LLC MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION
The following categories describe the different ways that Designer Audiology, LLC 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.
Treatment
Designer Audiology, LLC may use and disclose your protected health information to provide, coordinate, or manage
your audiologic treatment and any related services. Designer Audiology, LLC may also disclose your protected health
information to other third party providers involved in your audiologic/health care. For example, your protected health
information may be provided to a physician or other audiologic/health care provider (e.g. a specialist or laboratory) to
whom you have been referred to ensure that the physician or other audiologic/health care provider has the necessary
information to diagnose or treat you.
Payment
Designer Audiology, LLC 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 payers.
This may include certain activities that your health insurance plan may undertake before it approves or pays for the
audiologic/health care services Designer Audiology, LLC recommends 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, Designer Audiology, LLC may provide your health plan with medical
information about the audiologic/health care services Designer Audiology, LLC rendered to you for reimbursement
purposes.
Audiological/Health Care Operations
Designer Audiology, LLC may use and disclose your protected health information for audiologic/health care operation
purposes. These uses and disclosures are necessary to make sure that all patients receive quality care and for operation
and management purposes. For example, Designer Audiology, LLC may use your protected health information to review
the quality of the treatment and services you receive and to evaluate the performance of Designer Audiology, LLC’s
team members in caring for you. Designer Audiology, LLC also may disclose information to audiologists, physicians,
nurses, technicians, medical students, and other personnel for educational and learning purposes.
Treatment Communications
Designer Audiology, LLC may provide treatment communications concerning treatment alternatives or other health
related products or services. For communications for which Designer Audiology, LLC or a business associate may
receive financial remuneration in exchange for making the communication, Designer Audiology, LLC 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 and/or Owner,
Dr. Alicia D.D. Spoor, Owner, Designer Audiology, LLC 13364A Clarksville Pike Highland, MD 20777.
Fundraising Activities
Designer Audiology, LLC 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 Designer Audiology, LLC. 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 and/or Owner, Dr. Alicia D.D. Spoor, Owner, Designer Audiology, LLC 13364A
Clarksville Pike Highland, MD 20777.
Others Involved in Your Healthcare
Unless you object, Designer Audiology, LLC 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, Designer Audiology, LLC may disclose such
information, as necessary, if Designer Audiology, LLC determines that it is in your best interest based on professional
judgment. Also, for example, if you are brought into this office and are unable to communicate normally with your
clinician for some reason, Designer Audiology, LLC 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. Designer Audiology, LLC may also use and
disclose protected health information to notify such persons of your location, general condition, or death. Designer
Audiology, LLC also may coordinate with disaster relief agencies to make this type of notification. Designer Audiology,
LLC also may use professional judgment and 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.
Required by Law
Designer Audiology, LLC 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.
Public Health
Designer Audiology, LLC 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. Designer Audiology, LLC 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.
Business Associates
Designer Audiology, LLC may disclose your protected health information to business associates that perform
functions on Designer Audiology, LLC’s behalf or provide Designer Audiology, LLC with services if the information is
necessary for such functions or services. To protect your health information, however, Designer Audiology, LLC
require the business associate to appropriately safeguard your information.
Communicable Diseases
Designer Audiology, LLC 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.
Health Oversight
Designer Audiology, LLC 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 audiologic/health care system, government benefit programs, other government regulatory programs and civil rights laws.
Abuse or Neglect
Designer Audiology, LLC 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, Designer Audiology, LLC may disclose your protected health
information if Designer Audiology, LLC believes 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.
Food and Drug Administration
Designer Audiology, LLC 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.
Legal Proceedings
Designer Audiology, LLC 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.
Law Enforcement
Designer Audiology, LLC may disclose your protected health information, so long as applicable legal requirements are
met, for law enforcement purposes.
Coroners, Funeral Directors, and Organ Donation
Designer Audiology, LLC 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. Designer Audiology, LLC 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. Designer Audiology, LLC 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.
Research
Designer Audiology, LLC 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.
Serious Threat to Health or Safety
Consistent with applicable federal and state laws, Designer Audiology, LLC 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.
Military Activity and National Security
If you are involved with military, national security or intelligence activities or if you are in law enforcement custody,
Designer Audiology, LLC may disclose your protected health information to authorized officials so they may carry out
their legal duties under the law.
Workers’ Compensation
Designer Audiology, LLC may disclose your protected health information as authorized for workers’ compensation or
other similar programs that provide benefits for a work-related illness.
For Data Breach Notification Purposes
Designer Audiology, LLC may use or disclose your protected health information to provide legally required notices of
unauthorized access to or disclosure of your health information.
Required Uses and Disclosures
Under the law, Designer Audiology, LLC 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:
• Uses and disclosures of protected health information for marketing purposes for which Designer Audiology, LLC or
a business associate may receive remuneration; and
• 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 Designer Audiology, LLC 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.
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.
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 Designer Audiology, LLC uses for making decisions about you. To inspect and
copy your medical information, you must submit a written request to our Privacy Officer and/or Owner, Dr. Alicia
D.D. Spoor, Owner, Designer Audiology, LLC 13364A Clarksville Pike Highland, MD 20777. If you request a copy of
your information, Designer Audiology, LLC may charge you a reasonable fee for the costs of copying, mailing or other
costs incurred 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, Designer Audiology, LLC 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 and/or Owner, Dr. Alicia D.D. Spoor, Owner, at (443) 410 -4410 or Alicia.Spoor@DesignerAudiology.com if you have questions about access to your medical record.
Right to Request Restrictions
You may ask Designer Audiology, LLC 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 and/or Owner, Dr. Alicia D.D. Spoor, Owner,
Designer Audiology, LLC 13364A Clarksville Pike Highland, MD 20777. Your request must state the specific restriction
requested and to whom you want the restriction to apply. Designer Audiology, LLC 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 audiologic/health care operation purposes and such information you
wish to restrict pertains solely to an audiologic/health care item or service for which you have paid Designer Audiology,
LLC “out-of-pocket” in- full. If Designer Audiology, LLC believes 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 Designer
Audiology, LLC does agree to the requested restriction, Designer Audiology, LLC may not use or disclose your
protected health information in violation of that restriction unless it is needed to provide emergency treatment.
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. Designer Audiology, LLC will accommodate reasonable requests. You must request this by submitting
a written request to our Privacy Officer and/or Owner, Dr. Alicia D.D. Spoor, Owner, Designer Audiology, LLC 13364A
Clarksville Pike Highland, MD 20777.
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 Designer Audiology, LLC uses for making decisions about you, for as long as Designer Audiology, LLC maintains the protected health information. You must request for an amendment by submitting a written request to our Privacy Officer and/or Owner, Dr. Alicia D.D. Spoor, Owner, Designer Audiology, LLC 13364A Clarksville Pike Highland, MD 20777, and provide the reason(s) that support your request. In certain cases, Designer Audiology, LLC may deny your request for an amendment. If Designer Audiology, LLC denies your request for an amendment, you have the right to file a statement of disagreement with Designer Audiology, LLC and Designer
Audiology, LLC may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.
Right to an Accounting of Disclosures
You have the right to receive an accounting of certain disclosures Designer Audiology, LLC has 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 Designer Audiology, LLC 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 and/or Owner, Dr. Alicia D.D. Spoor, Owner, Designer Audiology, LLC 13364A Clarksville Pike Highland, MD 20777, and provide the reason(s) that support your request.
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 Designer Audiology, LLC 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 and/or Owner, Dr. Alicia D.D. Spoor, Owner, at (443) 410-4410 or Alicia.Spoor@DesignerAudiology.com. You may also obtain a copy of this Notice at www.DesignerAudiology.com.
COMPLAINTS OR QUESTIONS
If you believe your privacy rights have been violated, you may file a complaint with Designer Audiology, LLC 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 Designer Audiology, LLC, please contact our Privacy Officer and/or Owner, Dr. Alicia D.D. Spoor, Owner, at (443) 410-4410 or Alicia.Spoor@DesignerAudiology.com or the Corporate Privacy Officer at the address listed below. All complaints must be submitted in writing. Designer Audiology, LLC will not retaliate against you for
filing a complaint.
CHANGES TO THIS NOTICE
Designer Audiology, LLC reserves the right to change this Notice at any time. The new Notice will be effective for all health information Designer Audiology, LLC already has about you as well as any information received in the future. You can also obtain a revised Notice at www.DesignerAudiology.com or by contacting our Privacy Officer and/or Owner, Dr. Alicia D.D. Spoor, Owner, Designer Audiology, LLC 13364A Clarksville Pike Highland, MD 20777.
Designer Audiology
Attn: Corporate Privacy Officer
13364A Clarksville Pike
Highland, MD 20777
This Notice is effective as of April, 2013