Web site information: This information is unique to Internet transactions. It includes the Web site that linked you
to ours, your computer operating system, and the pages you viewed on our site. Some Web sites, including ours, may
also store “cookies” on your computer. Cookies collect technical data, like your Internet protocol (IP) address, operating
system, and session ID. They can also save certain information entered by you. Some of our Web sites contain more
information about our Web site privacy practices. Please read it when using the sites.
Who might get information about me from you?
We will share information about you only as permitted by law. We will not share your Nonpublic Personal Information
with other companies for their marketing purposes without your consent. There is no need to “opt out” or tell us not to do
this.
Disclosures include those that we feel are required to provide insurance claims or customer service, prevent fraud, perform
EAR -HIPPA Consent Information/Privacy Practices
Our HIPPA consent form signature is located at the bottom of our Patient Registration form. By signing the form you consent to our use and disclosure of protected health information about you for treatment and payment of healthcare. You have the right to revoke the consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have all ready made in reliance on your prior consent.
We understand your medical information is personal to you and we are committed to protecting the information about you. As our patient, we create medical records about your health, our care for you, and the services and/or items we provide to you as our patient. By law, we are required to make sure that your protected health information is kept private.
If you ever believe your privacy rights have been violated, you may file a complaint with Sharon Hirstein at Elkhart Audiology Rehab or the Secretary of the Department of Health and Human Services. All complaints must be in writing. You will not be penalized for filing complaints.
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. We will not sell your personal health information to any other entity.
Examples of how we will use or disclose your information:
• for treatment and referral of hearing or balance concerns
• to obtain payment and file insurance
• in emergency situations
• for appointment and patient recall reminders
• for our marketing or promotional events related to new hearing devices or treatment options and any other service or product updates (financially remunerated or otherwise) that could benefit you
• in response to certain requests arising out of law suits or other disputes
You have certain rights including:
• the right to inspect and request a copy of your records
• the right to amend
• the right to an accounting of disclosures
• the right to request restrictions
• the right to request confidential communications
• the right to a paper copy of this notice.
Additionally by signing the form, you acknowledge you are granting full authority to the audiologist and her assistants to administer and perform any and all treatments, test or diagnostic procedure to you, which may be advised or necessary.
Our HIPPA consent form signature is located at the bottom of our Patient Registration form. By signing the form you consent to our use and disclosure of protected health information about you for treatment and payment of healthcare. You have the right to revoke the consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have all ready made in reliance on your prior consent.
We understand your medical information is personal to you and we are committed to protecting the information about you. As our patient, we create medical records about your health, our care for you, and the services and/or items we provide to you as our patient. By law, we are required to make sure that your protected health information is kept private.
If you ever believe your privacy rights have been violated, you may file a complaint with Sharon Hirstein at Elkhart Audiology Rehab or the Secretary of the Department of Health and Human Services. All complaints must be in writing. You will not be penalized for filing complaints.
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. We will not sell your personal health information to any other entity.
Examples of how we will use or disclose your information:
• for treatment and referral of hearing or balance concerns
• to obtain payment and file insurance
• in emergency situations
• for appointment and patient recall reminders
• for our marketing or promotional events related to new hearing devices or treatment options and any other service or product updates (financially remunerated or otherwise) that could benefit you
• in response to certain requests arising out of law suits or other disputes
You have certain rights including:
• the right to inspect and request a copy of your records
• the right to amend
• the right to an accounting of disclosures
• the right to request restrictions
• the right to request confidential communications
• the right to a paper copy of this notice.
Additionally by signing the form, you acknowledge you are granting full authority to the audiologist and her assistants to administer and perform any and all treatments, test or diagnostic procedure to you, which may be advised or necessary.