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Notice of Privacy Practices

Last Updated: 11/27/25

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. (Effective Date: Nov 24, 2025)

Our commitment to your privacy

We understand that your protected health information (PHI) is personal. We are committed to protecting the privacy of your PHI, which includes information about your hearing health, evaluations, diagnoses, treatment, and payment for those services. We will:

  1. Maintain the privacy and security of your protected health information.
  2. Provide you with this Notice of our legal duties and privacy practices.
  3. Notify you following a breach of your unsecured protected health information.
  4. Abide by the terms of the Notice currently in effect.

If you have any questions about this Notice, please contact our Privacy Officer listed on the last page.

How we may use and disclose your protected health information (phi)

We may use and disclose your PHI without your written authorization for the following purposes:

1. For Treatment

We may use and disclose your PHI to provide, coordinate, and manage your health care and related services. This includes disclosing information to other treating health care providers, such as your Primary Care Physician (PCP) or an Ear, Nose, and Throat (ENT) specialist, to ensure they have the necessary information to treat you.

  • Example: We may share the results of your audiogram and hearing aid fitting details with your referring physician to coordinate your overall care.

2. For Payment

We may use and disclose your PHI to obtain payment for the audiology services we provide to you.

  • Example: We may share your diagnosis, service dates, and treatment plan with your insurance company, Medicare, or Medicaid to confirm coverage, verify eligibility, and submit claims for payment.

3. For Health Care Operations

We may use and disclose your PHI for our own health care operations to manage our practice, improve quality of care, and control costs.

  • Example: We may use your PHI to conduct quality assessment activities, review the performance of our staff, conduct training programs, or manage our electronic health records (EHR) system.

Required uses of health information

We may use or disclose your PHI for specific public benefits or purposes as required or permitted by law:

Public Health Activities

We may disclose PHI to public health authorities authorized to receive such information for preventing or controlling disease, injury, or disability.

Health Oversight Activities

We may disclose PHI to a health oversight agency for audits, investigations, inspections, and licensing purposes, as authorized by law.

Judicial and Administrative Proceedings

We may disclose your PHI in the course of any judicial or administrative proceeding, in response to a court order, subpoena, discovery request, or other lawful process.

Law Enforcement

We may disclose PHI to law enforcement officials in response to a subpoena, court order, warrant, summons, or other legal process for specific purposes, such as identifying or locating a suspect, fugitive, witness, or missing person.

Coroners, Medical Examiners, & Funeral Directors

We may disclose PHI to these parties for the purpose of identifying a deceased person or determining the cause of death.

Research

We may disclose PHI for research when the research has been approved by an Institutional Review Board (IRB) or a privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your PHI.

Specialized Government Functions

We may disclose PHI to units of the government with special functions, such as the U.S. military or correctional facilities, as authorized by law.

Averting a Serious Threat to Health or Safety

We may use and disclose your PHI when necessary to prevent a serious and imminent threat to your health or safety or the health and safety of the public or another person.

Disclosures that require an opportunity to object

Individuals Involved in Your Care or Payment for Care

Unless you object, we may share PHI with a family member, relative, friend, or any other person you identify who is involved in your care or payment for your care. If you are unavailable or incapacitated, we will use our professional judgment to decide if a disclosure is in your best interest.

Disclosures that require your written authorization

We must obtain your specific written authorization for the following uses and disclosures:

  1. Marketing: PHI disclosures that constitute marketing under HIPAA (e.g., communications where we receive financial remuneration for making the communication) require your authorization.
  2. Sale of PHI: Any disclosure of your PHI that constitutes a "sale" of PHI requires your authorization.
  3. Other Uses: Any uses or disclosures of PHI not covered by this Notice will be made only with your prior written authorization. You may revoke an authorization at any time by notifying our Privacy Officer in writing.

Sensitive Information and New York State Law

New York State law provides special, additional protections for certain types of health information, including:

  • Mental health and developmental disability records (Mental Hygiene Law)
  • HIV/AIDS-related information (Public Health Law Article 27-F)
  • Substance Use Disorder (SUD) information (as governed by 42 CFR Part 2)

We do not anticipate using or disclosing this type of health information. However, we are informing you that these categories of information are subject to more stringent New York State protections, and in most cases, a separate, specific written authorization or a court order is required for us to use or disclose this information, even for Treatment, Payment, or Health Care Operations.

Your individual privacy rights

You have the following rights regarding your PHI. To exercise any of these rights, please submit a written request to the Privacy Officer.

1. Right to Inspect and Copy Your Health Information

You have the right to inspect and obtain a copy of the PHI that we maintain about you in a Designated Record Set, including billing and medical records.

  • NY State Requirement: We must provide you with a copy of your records within 10 days of your written request, unless we notify you in writing within that time period that additional time is needed (up to 30 days total). We may charge a reasonable, cost-based fee not to exceed $0.75 per page or the actual cost of other media (e.g., CDs, USB drives), plus actual postage costs if mailing is requested.
  • We will provide your PHI in the format you request (paper or electronic), if readily producible.

2. Right to Request an Amendment

If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information. We may deny your request, but we will provide you with a written explanation of the denial and allow you to submit a statement of disagreement.

3. Right to an Accounting of Disclosures

You have the right to request a list of certain disclosures we have made of your PHI within the six years prior to your request for purposes other than Treatment, Payment, Health Care Operations, disclosures made with your authorization, disclosures to you, disclosures for facility directories, or disclosures to persons involved in your care. The first accounting in any 12-month period will be provided free of charge; subsequent requests may be subject to a reasonable, cost-based fee.

4. Right to Request Restrictions

You have the right to request a restriction or limitation on the PHI we use or disclose for Treatment, Payment, or Health Care Operations. We are not required to agree to your request, with one exception:

  • Mandatory Restriction: If you pay for a service or health care item out-of-pocket in full, you have the right to request that we not disclose PHI related to that service to your health plan/insurer. We are required to agree to this restriction, unless otherwise required by law.

5. Right to Request Confidential Communications

You have the right to request that we communicate with you about your health matters in a certain way or at a certain location. Your request must specify how or where you wish to be contacted and must be made in writing.

  • Example: You can ask that we only contact you at work, or only by mail. We will accommodate all reasonable requests.

6. Right to a Paper Copy of this Notice

You have the right to obtain a paper copy of this Notice, even if you have agreed to receive the Notice electronically.

7. Right to Be Notified of a Breach

You have the right to be notified if we, or our Business Associate, discover a breach of your unsecured PHI.

Changes to this notice

We reserve the right to change the terms of this Notice at any time. The new Notice will be effective for all PHI that we maintain at that time. We will post a copy of the current Notice in our practice and on our website at www.fortell.com. You may also obtain a copy of the revised Notice by contacting the Privacy Officer.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services (HHS).

To file a complaint with the Practice:

  • Contact the Privacy Officer below. All complaints must be submitted in writing.
  • You will not be penalized or retaliated against for filing a complaint.

To file a complaint with the Secretary of HHS:

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If you have any questions about this Notice of Privacy Practices, please contact privacy@fortell.com.