"HIPAA NOTICE OF PRIVACY PRACTICES”
THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Riverside Hearing Aid Center
Greggory G Richardson
Hearing Aid Dispencer License # HA7089
6709 Brockton Ave. Riverside CA 92506
951-686-2334 Fax 951-369-8500
PLEASE REVIEW IT CAREFULLY.
Individually identifiable information about your past, present, or future hearing condition, the provision of hearing health care to you, or payment for the hearing healthcare is considered “Protected Health Information” (PHI). We are required to extend certain protections to your PHI, and to give you this Notice about our privacy practices that explains how, when and why we may use or disclose your PHI. Except in specified circumstances, we may only disclose the minimum necessary to accomplish the intended purpose of the use or disclosure.
Treatment We may use hearing health information about you to provide you with enhancement services. We may disclose health information about you to doctors, nurses, technicians, office staff or other personnel who are involved in taking care of you.
Payment Your PHI will be used as needed, to obtain payment for your health care services. For example, we may need to give your health plan health information about a service you received here so your health plan with pay us or reimburse you for the service. We may also tell your health plan about hearing devices that you are going to receive to obtain prior approval or to determine whether your plan will cover the hearing prosthetics.
Health Care Operations We may use and disclose hearing health information about you in order to run the office and make sure that you and our other clients receive quality care. For example, we may use your hearing health information to evaluate the performance of our staff in caring for you. We may also use hearing health information about all or many clients to help us decide what additional services we should offer, how we can become more efficient, or whether certain new hearing instrument(s) are effective.
Appointment Reminders We may contact you as a reminder by phone, email or postcard that you have or need an appointment for your hearing instruments(s) at the office.
Other permitted and required uses and disclosures will be made only with consent, authorization, or opportunity to object unless required by law.
You may revoke this authorization, at any time by giving us written notice. Your revocation will be effective when we receive it, but it will not apply to any uses and disclosures which occurred before that time.
You have the right to inspect and copy your PHI under federal law, however you may not request the information with reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and PHI that is subject to law that prohibits access to PHI.
You have the right to request a restriction of your PHI. This means you may ask us not to use or disclose any part of your PHI for the purposes of treatment, payment or healthcare operations. You may also request that any part of your PHI not be disclosed to family members or friends who may be involved in your care or for notification purposes as described on this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.
You have the right to request to receive confidential communication from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively, i.e. electronically.
You may have the right to amend your PHI. If we deny your request for 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.
You have the right to receive an accounting of certain disclosures we may have made, if any, of your PHI. We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.
Complaints You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against your 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 PHI. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone.
6709 Brockton Ave. Riverside CA 92506
951-686-2334 Fax 951-369-8500
Full HIPPA Print out available upon request at:
6709 Brockton Ave. Riverside CA 92506
Acknowledgement of Notice of Privacy Practices
I have read and understand my rights as explained by Riverside Hearing Aid Center Notice of Privacy Practices.
__________________________________ _____________________________________________ ______________________
Print Name Signature Date
“HIPAA NOTICE OF PRIVACY PRACTICES”
Who We May Discuss your Hearing with or about
The audiogram the graph showing the results of the pure-tone hearing test type, degree, and configuration of your hearing loss. / The range of frequencies or pitch of the sound is referred to in Hertz (Hz) tested by the Hearing aid Dispenser are 125 Hz, 250 Hz, 500 Hz, 1000 Hz, 2000 Hz, 3000Hz, 4000 Hz, 6000Hz, and 8000 Hz. / The intensity or loudness of the sound is measured in decibels (dB) / Speech Audiometry – The portion of an audiological evaluation that uses speech stimuli to measure the auditory system. / Speech Reception Thresholds (SRTs) utilizing two–syllable spondee words and the assessment of Word Recognition / Speech Discrimination scores utilizing single syllable words in a carrier phrase. Some speech audiometry tests use sentence materials instead of single word materials.
Sensorineural hearing loss (SNHL) is a type of hearing loss, or deafness, in which the root cause lies in the inner ear or sensory organ (cochlea and associated structures) or the vestibulocochlear nerve (cranial nerve VIII) or neural part. / Mixed hearing loss (MHL) is a combination of conductive and sensorineural hearing loss, which means there is damage in both the outer or middle ear and in the inner ear. This type of hearing loss ranges in severity from mild to profound. / Conductive hearing loss (CHL) occurs when there is a problem conducting sound waves anywhere along the route through the outer ear, tympanic membrane (eardrum), or middle ear (ossicles). This type of hearing loss may occur in conjunction with sensorineural hearing loss (mixed hearing loss) or alone. / Noise-induced hearing loss (NIHL) is hearing impairment resulting from exposure to loud sound. People may have a loss of perception of a narrow range of frequencies, impaired cognitive perception of sound, or other impairment, including sensitivity to sound or ringing in the ears. / Age-related hearing loss (presbycusis) is the loss of hearing that gradually occurs in most of us as we grow older. It is one of the most common conditions affecting older and elderly adults. / Hereditary Hearing Impairment – Inherited hearing loss that is passed down through the family. / Congenital Hearing Loss – The presence of hearing loss at or before birth. / Bilateral hearing loss in both ears / Unilateral hearing loss in one ear / Symmetrical the degree and configuration of hearing loss are the same in each ear / Asymmetrical degree and configuration of hearing loss are different in each ear. / Auditory Processing Disorder (APD) – Inability of an individual with normal hearing and intelligence to differentiate, recognize, or understand sounds normally. / Tinnitus – Sensation of a ringing, roaring, or buzzing sound in the ears or head. It is often associated with many forms of hearing loss and noise exposure. Learn more about tinnitus. / Tinnitus is the perception of sound in the head or the ears. The term tinnitus derives from the Latin word tinnire, meaning to ring. / Cerumen (Ear Wax) – Yellow secretion from glands in the outer ear canal that keeps the skin of the ear canal dry and protected from infection. / Otitis Media – Inflammation of the middle ear caused by infection. / Cognition – Thinking skills that include perception, memory, awareness, reasoning, judgment, intellect, and imagination. / Dizziness – Physical unsteadiness, imbalance, and lightheadedness associated with balance disorders. Learn more about balance disorders and dizziness. / Vertigo – Illusion of movement; a sensation as if the external world were revolving around an individual (objective vertigo) or as if the individual were revolving in space (subjective vertigo). / Tympanoplasty – Surgical repair of the eardrum (tympanic membrane) or bones of the middle ear ect. Outer Ear – pinna, or auricle, and the ear canal, Helix, Concha, Antitragus, Aperture, Tragus, Cymba,
Kaiser, Aetna Health Inc., Anthem, Blue Cross of California, Blue Shield of California, CalOptima, Care 1st Health Plan, CareMore Health Plan, Central Health Medicare Plan, Health Net of California, Inc., Medi-Cal, Medicaid, Kaiser Permanente, Partnership Healthplan of California, Scan, Molina Health Care, United Health Care, Health Net, Medicare AARP, Tri Care, (IEHP) Inland Empire Health Plan, kp.org, Champva, Scan Medi-Cal Health Plan Inter Valley Health Plan, InterValley Health Plan, Riverside County Employees Health Plan, Exclusive Care, Kaiser, Scan Health Plan, Aetna, Operator Engineers, Riverside Medical Center, Medicare Advantage plans,
Completely-In-Canal (CIC), In-The-Canal (ITC), In-The-Ear Fullshell, HalfShell, (ITE) Receiver-In-Canal (RIC) Behind-The-Ear (BTE) Over the ear (OTC) (Ric) Receiver in canal, Invisible, Impressions, Power Aid, FeedBack, Echo, Barrel Effect, Occluded, Tinny, Output, Occlusion, Lispy, Muffled, Harsh, Frequency Lowering, Static, Buzzing, Booming Distorted, Canal Lock, Tinnitus sound masking hearing aids, Earhook, Wax Guard, Thin Tube, Skeleton Mold, Power Aid, Bi Cross, Cross, Bluetooth, wireless,
Hearing Impairment and hearing disability, Life style activities and difficulties, such as church, restaurants, TV, Meetings, work environment, speech in noise, one on one, Grand children, movies, Tele phone, cell phone, apple iphone, music, streaming, remote control