Notice of Privacy Practices
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We are required by law to maintain the privacy of your protected health information and to provide you with this notice, which
explains our legal duties and privacy practices with respect to your protected health information. We must abide by the
terms set forth in this notice. However, we reserve the right to change the terms of this notice and to make new notice
provisions effective for all protected health information we maintain. Should any revisions occur you will be notified at your
first appointment following the revision.
Uses and Disclosures of Your Protected Health Information:
Treatment. We may use and disclose your protected health information to provide, coordinate, or manage your health care
and any related services. We may also disclose your protected health information to other health care providers who may be
treating you or involved in your health care. For example – we may disclose your protected health information to your treating
physician.
Payment. We may use and disclose your protected health information to obtain payment for the health care services we
provide you or to determine whether we may obtain payment for services we recommend to you. We may also disclose your
protected health information to another health care provider, health care clearinghouse or health plan for services it provided
to you. For example – we may include with a bill to a third-party payer information that identifies you, your diagnosis,
procedures performed, and supplies used in rendering the service.
Health Care Operations. We may use and disclose your protected health information to support our business activities. For
example – we may use your protected health information to review and evaluate our treatment and services or to evaluate
our staff’s performance while caring for you. We may also disclose your protected health information to third party business
associates who perform certain activities for us (e.g., billing or transcription services). Finally, we may disclose to certain
third parties a limited data set containing your protected health information for certain business activities.
Appointment Reminders and Treatment Alternatives. We may use and disclose your protected health information to
contact you as a reminder about scheduled appointments or treatment, or to tell you about or to recommend possible
alternative treatments or other health-related benefits or services that may be of interest to you.
Persons Involved in Your Care. We may use and disclose to a family member, a relative, a close friend, or any other person
you identify, your protected health information that is directly relevant to the person’s involvement in your care or payment
related to your care, unless you object to such disclosure. If you are unable to agree or object to a disclosure, we may
disclose the information as necessary if we determine that it is in your best interest based on our professional judgment.
Notification. We may use or disclose your protected health information to notify or assist in notifying a family member,
personal representative or other person responsible for your care, of your location, general condition or death.
Disaster relief. We may use or disclose your protected health information to an authorized public or private entity to assist in
disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.
Research. We may use or disclose your protected health information to researchers whose research has been approved
by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of
your health information. We may also disclose to certain third parties a limited data set containing your protected health
information for research purposes.
As Required by Law. We may use or disclose your protected health information to the extent the use or disclosure is
required by law. If required by law, you will be notified of any such uses or disclosures.
Public Health. We may disclose your protected health information for public health activities to a public health authority that
is permitted by law to collect or receive the information. Disclosures will be made for purposes on controlling disease, injury
or disability. If directed by the public health authority, we may disclose your protected health information to a foreign
government agency that is collaborating with the public health authority.
Abuse or Neglect. We may disclose your protected health information to a public health authority that is authorized by law to
receive reports of child abuse or neglect. If we believe you are a victim of abuse, neglect or domestic violence, we also may
disclose your protected health information to the governmental agency that is authorized to receive this information. All
disclosures will be consistent with the requirements of the applicable laws.
Communicable Diseases. If authorized by law, we may disclose your protected health information to a person who may
have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a communicable
disease.
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 the disclosure is expressly authorized;
or, if certain conditions have been satisfied, in response to a subpoena, discovery request or other lawful process.
Law Enforcement. If certain legal requirements are met, we may disclose your protected health information to a law
enforcement official for law enforcement purposes, including legal processes; identification and location of suspects,
fugitives, material witnesses or missing persons; information regarding victims of a crime; suspicion that death has
occurred as a result of criminal conduct; evidence of criminal conduct occurring on our premises; and, in a medical
emergency, reporting criminal conduct not on our premises.
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 as required 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 his/her duties or in reasonable anticipation of death. Finally, we may
use or disclose your protected health information for facilitating organ, eye or tissue donation and transplantation.
To Avert a Serious Threat to Public Health or Safety. Consistent with applicable laws, if we believe using and disclosing your
protected health information is necessary to prevent or lessen a serious and imminent threat to the health or safety of a
person or the public, we may use and disclose your protected health information. We may also disclose your protected
health information if it is necessary for law enforcement to identify or apprehend an individual.
Military Activity and National Security. When the appropriate conditions apply, we may use or disclose your protected
health information: (1) for activities deemed necessary by appropriate military command authorities; (2) for determining your
eligibility for benefits by the Department of Veterans Affairs; or (3) to foreign military authority if you are a member of that
foreign military service. We may also disclose your protected health information to authorized federal officials for conducting
national security and intelligence activities, including for the provision of protective services to the President or others legally
authorized.
Workers’ Compensation. We may use and disclose your protected health information for workers’ compensation or similar
programs that provide benefits for work-related injuries or illness.
Department of Health and Human Services. As required by law, we may disclose your protected health information to the
Department of Health and Human Services to determine our compliance with applicable laws.
Written Authorization. Except as stated in this notice, we will not use or disclose your protected health information without
your written authorization. You may revoke this authorization at any time, in writing, except to the extent that we have used or
disclosed your information in reliance on the authorization.
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.
Inmates. We may use and disclose your protected health information if you are an inmate of a correctional facility and we
created or received your protected health information in the course of providing care to you.
Your Health Information Rights:
Copy of This Notice. You have the right to receive a paper copy of this notice upon request. You may obtain a copy by asking
our receptionist at your next visit or by calling and asking us to mail you a copy.
Inspect and Copy. You have the right to inspect and copy the protected health information that we maintain about you in our
designated record set for as long as we maintain that information. This designated set includes your medical and billing
records, as well as any other records we use for making decisions about you. You may not inspect or copy psychotherapy
notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding;
or protected health information that is subject to law that prohibits access to protected health information. In some
circumstances, you may have a right to review our denial.
If you wish to inspect or copy your medical information, you must submit your request in writing to the attention of our privacy
Officer, c/o Osmond Hearing Center, 1618 E. Republic Rd., Springfield, MO 65804. We may charge you a fee for the costs of
copying, mailing, or other supplies used in fulfilling your request. You may mail your request or bring it to our office. We
have 30 days to respond to your request for information that we maintain at our practice sites. If the information is stored off-
site, we have up to 60 days to respond, but must inform you of this delay.
Request Amendment. You have the right to request that we amend your protected health information. You must make this
request in writing to our Privacy Officer. The request must state the reason for the amendment.
We may deny your request if it is not in writing or does not state the reason for the amendment. We may also deny your
request if the information was not created by us, unless you provide reasonable information that the person who created it is
no longer available to make the amendment; is not part of the record which you are permitted to inspect and copy; the
information is not part of our designated record; or is accurate and complete, in our opinion.
Request Restrictions. You have the right to request a restriction or limitation of how we use or disclose your protected
health information for treatment, payment, or health care operations; to persons involved in your care; or for notification
purposes as set forth in this notice. Although we are not required to agree to your requested restriction, if we do agree, we
will comply with your request unless the information is needed for emergency treatment. Please contact our Privacy Officer
as set forth in this notice to request a restriction.
Accounting of Disclosures. You have the right to request a list of our disclosures of your protected health information,
except for disclosures for treatment, payment, or health care operations; to you; incident to a use or disclosure set forth in
this notice; to persons involved in your care; for notifications purposes; for national security or intelligence purposes; to law
enforcement officials; as part of a limited data set; that occurred before April 14, 2003 or six years from the day of the
request. Your request must be in writing and must state the time period for the requested information.
Your first request for a list of disclosures within a 12-month period will be free. If you request an additional list within 12-
months of the first request, we may charge you a fee for the costs of providing the subsequent list. We will notify you of such
costs and afford you the opportunity to withdraw your request before any costs are incurred.
Request Confidential Communications. You have the right to request how we communicate with you to preserve your
privacy. We may condition the accommodation by asking you for information as to how payment will be handled or
specification of an alternative address or other method of contact. You must submit your request in writing to our Privacy
Officer. The request must specify how or where we are to contact you. We will accommodate all reasonable requests.
File a Complaint. You have the right to file a complaint with or Privacy Officer or with the Secretary of the Department of Health
and Human Resources if you believe we have violated your privacy rights. Complaints to our Privacy Officer must be in
writing. We will not retaliate against you for filing a complaint.
explains our legal duties and privacy practices with respect to your protected health information. We must abide by the
terms set forth in this notice. However, we reserve the right to change the terms of this notice and to make new notice
provisions effective for all protected health information we maintain. Should any revisions occur you will be notified at your
first appointment following the revision.
Uses and Disclosures of Your Protected Health Information:
Treatment. We may use and disclose your protected health information to provide, coordinate, or manage your health care
and any related services. We may also disclose your protected health information to other health care providers who may be
treating you or involved in your health care. For example – we may disclose your protected health information to your treating
physician.
Payment. We may use and disclose your protected health information to obtain payment for the health care services we
provide you or to determine whether we may obtain payment for services we recommend to you. We may also disclose your
protected health information to another health care provider, health care clearinghouse or health plan for services it provided
to you. For example – we may include with a bill to a third-party payer information that identifies you, your diagnosis,
procedures performed, and supplies used in rendering the service.
Health Care Operations. We may use and disclose your protected health information to support our business activities. For
example – we may use your protected health information to review and evaluate our treatment and services or to evaluate
our staff’s performance while caring for you. We may also disclose your protected health information to third party business
associates who perform certain activities for us (e.g., billing or transcription services). Finally, we may disclose to certain
third parties a limited data set containing your protected health information for certain business activities.
Appointment Reminders and Treatment Alternatives. We may use and disclose your protected health information to
contact you as a reminder about scheduled appointments or treatment, or to tell you about or to recommend possible
alternative treatments or other health-related benefits or services that may be of interest to you.
Persons Involved in Your Care. We may use and disclose to a family member, a relative, a close friend, or any other person
you identify, your protected health information that is directly relevant to the person’s involvement in your care or payment
related to your care, unless you object to such disclosure. If you are unable to agree or object to a disclosure, we may
disclose the information as necessary if we determine that it is in your best interest based on our professional judgment.
Notification. We may use or disclose your protected health information to notify or assist in notifying a family member,
personal representative or other person responsible for your care, of your location, general condition or death.
Disaster relief. We may use or disclose your protected health information to an authorized public or private entity to assist in
disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.
Research. We may use or disclose your protected health information to researchers whose research has been approved
by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of
your health information. We may also disclose to certain third parties a limited data set containing your protected health
information for research purposes.
As Required by Law. We may use or disclose your protected health information to the extent the use or disclosure is
required by law. If required by law, you will be notified of any such uses or disclosures.
Public Health. We may disclose your protected health information for public health activities to a public health authority that
is permitted by law to collect or receive the information. Disclosures will be made for purposes on controlling disease, injury
or disability. If directed by the public health authority, we may disclose your protected health information to a foreign
government agency that is collaborating with the public health authority.
Abuse or Neglect. We may disclose your protected health information to a public health authority that is authorized by law to
receive reports of child abuse or neglect. If we believe you are a victim of abuse, neglect or domestic violence, we also may
disclose your protected health information to the governmental agency that is authorized to receive this information. All
disclosures will be consistent with the requirements of the applicable laws.
Communicable Diseases. If authorized by law, we may disclose your protected health information to a person who may
have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a communicable
disease.
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 the disclosure is expressly authorized;
or, if certain conditions have been satisfied, in response to a subpoena, discovery request or other lawful process.
Law Enforcement. If certain legal requirements are met, we may disclose your protected health information to a law
enforcement official for law enforcement purposes, including legal processes; identification and location of suspects,
fugitives, material witnesses or missing persons; information regarding victims of a crime; suspicion that death has
occurred as a result of criminal conduct; evidence of criminal conduct occurring on our premises; and, in a medical
emergency, reporting criminal conduct not on our premises.
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 as required 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 his/her duties or in reasonable anticipation of death. Finally, we may
use or disclose your protected health information for facilitating organ, eye or tissue donation and transplantation.
To Avert a Serious Threat to Public Health or Safety. Consistent with applicable laws, if we believe using and disclosing your
protected health information is necessary to prevent or lessen a serious and imminent threat to the health or safety of a
person or the public, we may use and disclose your protected health information. We may also disclose your protected
health information if it is necessary for law enforcement to identify or apprehend an individual.
Military Activity and National Security. When the appropriate conditions apply, we may use or disclose your protected
health information: (1) for activities deemed necessary by appropriate military command authorities; (2) for determining your
eligibility for benefits by the Department of Veterans Affairs; or (3) to foreign military authority if you are a member of that
foreign military service. We may also disclose your protected health information to authorized federal officials for conducting
national security and intelligence activities, including for the provision of protective services to the President or others legally
authorized.
Workers’ Compensation. We may use and disclose your protected health information for workers’ compensation or similar
programs that provide benefits for work-related injuries or illness.
Department of Health and Human Services. As required by law, we may disclose your protected health information to the
Department of Health and Human Services to determine our compliance with applicable laws.
Written Authorization. Except as stated in this notice, we will not use or disclose your protected health information without
your written authorization. You may revoke this authorization at any time, in writing, except to the extent that we have used or
disclosed your information in reliance on the authorization.
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.
Inmates. We may use and disclose your protected health information if you are an inmate of a correctional facility and we
created or received your protected health information in the course of providing care to you.
Your Health Information Rights:
Copy of This Notice. You have the right to receive a paper copy of this notice upon request. You may obtain a copy by asking
our receptionist at your next visit or by calling and asking us to mail you a copy.
Inspect and Copy. You have the right to inspect and copy the protected health information that we maintain about you in our
designated record set for as long as we maintain that information. This designated set includes your medical and billing
records, as well as any other records we use for making decisions about you. You may not inspect or copy psychotherapy
notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding;
or protected health information that is subject to law that prohibits access to protected health information. In some
circumstances, you may have a right to review our denial.
If you wish to inspect or copy your medical information, you must submit your request in writing to the attention of our privacy
Officer, c/o Osmond Hearing Center, 1618 E. Republic Rd., Springfield, MO 65804. We may charge you a fee for the costs of
copying, mailing, or other supplies used in fulfilling your request. You may mail your request or bring it to our office. We
have 30 days to respond to your request for information that we maintain at our practice sites. If the information is stored off-
site, we have up to 60 days to respond, but must inform you of this delay.
Request Amendment. You have the right to request that we amend your protected health information. You must make this
request in writing to our Privacy Officer. The request must state the reason for the amendment.
We may deny your request if it is not in writing or does not state the reason for the amendment. We may also deny your
request if the information was not created by us, unless you provide reasonable information that the person who created it is
no longer available to make the amendment; is not part of the record which you are permitted to inspect and copy; the
information is not part of our designated record; or is accurate and complete, in our opinion.
Request Restrictions. You have the right to request a restriction or limitation of how we use or disclose your protected
health information for treatment, payment, or health care operations; to persons involved in your care; or for notification
purposes as set forth in this notice. Although we are not required to agree to your requested restriction, if we do agree, we
will comply with your request unless the information is needed for emergency treatment. Please contact our Privacy Officer
as set forth in this notice to request a restriction.
Accounting of Disclosures. You have the right to request a list of our disclosures of your protected health information,
except for disclosures for treatment, payment, or health care operations; to you; incident to a use or disclosure set forth in
this notice; to persons involved in your care; for notifications purposes; for national security or intelligence purposes; to law
enforcement officials; as part of a limited data set; that occurred before April 14, 2003 or six years from the day of the
request. Your request must be in writing and must state the time period for the requested information.
Your first request for a list of disclosures within a 12-month period will be free. If you request an additional list within 12-
months of the first request, we may charge you a fee for the costs of providing the subsequent list. We will notify you of such
costs and afford you the opportunity to withdraw your request before any costs are incurred.
Request Confidential Communications. You have the right to request how we communicate with you to preserve your
privacy. We may condition the accommodation by asking you for information as to how payment will be handled or
specification of an alternative address or other method of contact. You must submit your request in writing to our Privacy
Officer. The request must specify how or where we are to contact you. We will accommodate all reasonable requests.
File a Complaint. You have the right to file a complaint with or Privacy Officer or with the Secretary of the Department of Health
and Human Resources if you believe we have violated your privacy rights. Complaints to our Privacy Officer must be in
writing. We will not retaliate against you for filing a complaint.
| 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. |
| For More Information: If you have questions or would like additional information, you may contact our Privacy Officer at: 1618 E Republic Road, Springfield, MO 65804 (417) 447-4500 or toll free 888-303-9630 |