HIS 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.

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to evaluate, carry out treatment, payment or operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

1.  Uses and Disclosures of Protected Health Information:

Uses and Disclosures of Protected Health Information: Your protected health information may be used and disclosed by your provider, our office staff and others outside of our office that are involved in your evaluation, care and treatment for the purpose of providing Center for Hearing services to you, to pay your health care bills, to support the operation of the Center for Hearing, and any other use required by law.

Treatment: We will use and disclose your protected health information to evaluate, provide, coordinate, or manage your care and any related services. This includes the coordination or management of your care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Payment: Your protected health information will be used, as needed, to obtain payment for your care and/or services.

Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of the Center for Hearing. These activities include, but are not limited to, quality assessment activities, employee review activities, training, licensing, and conducting or arranging for other business activities. For example, we may use a

sign-in sheet at the registration desk where you will be asked to sign your name and indicate your provider. We may also call you by name in the waiting room when your provider is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.

We may use or disclose your protected health information in the following situations without your authorization. These situations include as Required by Law; Public Health issues as required by law; Communicable Diseases; Health Oversight, Abuse or Neglect; Food and Drug Administration requirements; Legal Proceedings; Law Enforcement; Coroners; Funeral Directors, Organ Donation and Research; Criminal Activity; Military Activity and National Security; Workers’ Compensation; Inmates; and Other Required Uses and Disclosures. Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500.

Other Permitted and Required Uses and Disclosures will be made only with your consent, authorization, or opportunity to object unless required by law.

You may revoke this authorization, at any time, in writing, except to the extent that your provider or the Center for Hearing has taken an action in reliance on the use or disclosure indicated in the authorization.

2.  Your Rights:

The following is a statement of your rights with respect to your protected health information (PHI).

You have the right to inspect and obtain a copy of your protected health information. Under federal law, however, you may not inspect or obtain a copy of 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.

You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or center 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 of Privacy Practices. Your request must state, in writing, the specific restriction requested and to whom you want the restriction to apply. Your provider is not required to agree to a restriction that you may request. If your provider believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Professional.

You have the right to request to receive confidential communications 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 have your physician amend your protected health information. 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 have made, if any, of your protected health information. The Center for Hearing reserves the right to change the terms of this notice at any time. You may obtain a revised Notice of Privacy Practices by calling the office and requesting a copy of the revised copy be sent in the mail or by asking for a copy at the time of the next appointment.

3. 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 Officer of your complaint We will not retaliate against you for filing a complaint.

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 HIPAA Compliance Officer in person or by phone at our main office number.

Center for Hearing

625 Tamiami Trail N., Suite 301

Naples, FL 34102

Phone: (239) 434-0086 Facsimile: (239) 434-9029