NOTICE OF PRIVACY PRACTICES
Majestic Hearing and Tinnitus Centers LLC must collect timely and accurate health information
about you and make that information available to members of your health care team in this
agency, so that they can accurately diagnose your condition and provide the care you need.
There may also be times when your health information will be sent to service providers outside
this agency for services that this agency cannot provide. It is the legal duty of Majestic Hearing
and Tinnitus Centers LLC to protect your health information from unauthorized use or disclosure
while providing health care, obtaining payment for that health care and for other services
relating to your health care.
The purpose of this Notice of Privacy Practices is to inform you about how your health
information may be used within Majestic Hearing and Tinnitus Centers LLC, as well as reasons
why your health information could be sent to other service providers outside of this agency.
This Notice describes your rights in regards to the protection of your health information and how
you may exercise those rights. This Notice also gives you the names of contacts should you
have questions or comments about the policies and procedures Majestic Hearing and Tinnitus
Centers LLC uses to protect the privacy of your health information.
Please review this document carefully and ask for clarification if you do not understand any
portion of it.
Client Acknowledgement
I have received Majestic Hearing and Tinnitus Centers LLC’s Notice of Privacy Practices, which
describes this agency’s methods for protecting the privacy of my health information that is used
in providing health care services to me.
___________________________________/_____________
Client (or Personal Representative) Date
Note: Majestic Hearing and Tinnitus Centers LLC. Client retains the Notice of Privacy Practices
document.
Responsibilities of Majestic Hearing and Tinnitus Centers LLC:
Majestic Hearing and Tinnitus Centers LLC is required by state and federal law to protect the
privacy of your health information that may identify you. This health information includes mental
health, developmental disability and/or substance abuse services that are provided to you,
payment for those health care services, or other health care operations provided on your behalf.
This agency is required by law to inform you of our legal duties and privacy practices with
respect to your health information through this Notice of Privacy Practices. This Notice
describes the ways we may share your past, present and future health information, ensuring
that we use and/or disclose this information only as we have described in this Notice. We do,
however, reserve the right to change our privacy practices and the terms of this Notice, and to
make the new Notice provisions effective for all health information we maintain. Any changes
to this Notice will be posted [in our agency offices (applies only to providers with direct
relationship)] and on our agency website at (majestichac.com). Copies of any revised Notices
will be available to you upon request.
If at any time, you have questions or concerns about the information in this Notice or about our
agency’s privacy policies, procedures and practices, you may contact our agency at
(888)537-3280.
Use and Disclosure of Health Information without Your Authorization
Treatment
Majestic Hearing and Tinnitus Centers LLC may use your health information, as needed, in
order to provide, coordinate or manage your health care and related services. This includes
sharing your health information with other health care providers within this agency.
Example: Your treatment/habilitation team, composed of staff such as doctors, nurses, and
social workers, specialists will need to review your treatment and discuss plans for your
discharge.
We will disclose your health information outside of this agency for treatment purposes only with
your consent or when otherwise allowed under state or federal law. [The following is based upon
State law (GS 90-109.1) and applies to substance abuse providers, “If you request treatment
and rehabilitation for drug dependence, your request will be treated as confidential. We will not
refer you to another person for treatment and rehabilitation without your consent.”]
Example: We may disclose your health information to other mental health facilities or
professionals (i.e., community based area mental health, developmental disabilities and
substance abuse services program or psychiatric service at UNC Hospitals) in order to
coordinate your care.
Example: We may share your health information with a health care provider for emergency
services.
Payment for Services
The treatment provided to you will be shared with our agency’s billing department so a bill can
be prepared for services rendered. We may also share your health information with agency
staff who review services provided to you to make certain you have received appropriate care
and treatment. We will not disclose your health information outside of this agency for billing
purposes (i.e., bill your insurance company) without your consent [the following exception is not
applicable to substance abuse providers] except in certain situations when we need to
determine if you are eligible for benefits such as Medicaid, Medicare or Social Security.
Example: A Social Worker may contact your local Department of Social Services to determine if
you are currently eligible for Medicaid or if you would qualify for Medicaid. (Example not
applicable for substance abuse providers)
Example: Our billing department will collect insurance and other financial information from you
at the time of admission.
Health Care Operations
Majestic Hearing and Tinnitus Centers LLC may use or disclose your health information in
performing a variety of business activities that we call “health care operations”. Some examples
of how we may use or disclose your health information for health care operations are:

• Review the care you receive here and evaluate the performance of your
  treatment/habilitation team to ensure you have received quality care.
• Review and evaluate the skills, qualifications and performance of health care providers
  who are taking care of you.
• Provide training programs for agency staff, students and volunteers.
• Cooperate with outside organizations that review and determine the quality of care that
  you receive.
• Provide information to professional organizations that evaluate, certify or license health
  care providers, staff or facilities.
• Allow our agency attorney to use your health information when representing this agency
  in legal matters.
• Resolve grievances within our agency.
• Provide information to your internal client advocate who is available to represent your
  interests upon your request.
  Other Circumstances
  Majestic Hearing and Tinnitus Centers LLC may disclose your health information for those
  circumstances that have been determined to be so important that your authorization may not be
  required. Prior to disclosing your health information, we will evaluate each request to ensure
  that only necessary information will be disclosed. Those circumstances include disclosures that
  are:
• Required by law;
• For public health activities. For example, we may disclose health information to public
  health authorities if you have a communicable disease and we have reason to believe, based
  upon information provided to us, that there is a public health risk such as evidence of your
  noncompliance with your treatment plan. If you suffer from a communicable disease such as
  tuberculosis or HIV/AIDS, information about your disease will be treated as confidential. Other
  than circumstances described to you in other sections of this Notice, we will not release any
  information about your communicable disease except as required to protect public health or the
  spread of a disease, or at the request of the State or Local Health Director;
• Regarding abuse, neglect or domestic violence; (Not applicable to substance abuse
  providers – for substance abuse providers say “Regarding child abuse or neglect”)
• For health oversight activities such as licensing of nursing homes;
• For law enforcement purposes unless otherwise prohibited by state or federal law; [Not
  applicable to substance abuse providers – for substance abuse providers say, “If you request
  treatment and rehabilitation for drug dependence, we will not disclose your name to any police
  officer or other law-enforcement officer unless you authorize such disclosure; except that if you
  later commit a crime or threaten to commit a crime on the premises of this agency or against
  program personnel, law enforcement may be notified.”]
• For court proceedings such as court orders to appear in court;
• Related to death such as disclosure to a funeral director;
• Related to donation of organs or tissue;
• To avert a serious threat to the health or safety of a person or the public;
• Related to specialized government activities such as national security;
• To correctional institutions or other law enforcement officials when you are in their
  custody;
• For Worker’s Compensation in cases pending before the Industrial Commission; (Not
  applicable to substance abuse providers)
• To your next of kin or other person involved in your care upon their request; however,
  information to be disclosed will be limited to admission, transfer, discharge, referrals and
  appointments and you will be notified of this request; (Not applicable to substance abuse
  providers) and
• Related to medical research.
  Contacting You
  Majestic Hearing and Tinnitus Centers LLC may use your health information to contact you to:
• Remind you of upcoming appointments;
  Example: This agency may send an appointment reminder on a folded postcard to your home
  to remind you of a scheduled appointment.
  Example: This agency may send a letter to your home concerning the need for follow up care of
  medical conditions.
• Make you aware of alternative treatment, services, products or health care providers that
  may be of interest to you;
  Example: If you are receiving treatment for a particular condition and your health care team
  learns of new or alternative treatments, we may contact you to inform you of such possibilities.
• Contact you to request your participation in raising funds for this agency. If you object to
  being contacted in this way for fund-raising efforts, you must notify our Privacy Official who is
  listed in this Notice.
  Example: If our agency Foundation requested information be sent to you about an upcoming
  fundraising event, we may send the information to your home.
  Disclosure of Your Health Information That Allows You An Opportunity To Object
  There are certain circumstances where we may disclose your health information and you have
  an opportunity to object. Such circumstances include:
• The professional responsible for your care may disclose your admission to or discharge
  from this agency to your next of kin (Not applicable to substance abuse providers).
• Disclosure to public or private agencies providing disaster relief.
  Example: We may share your health information with the American Red Cross following a
  major disaster such as a flood.
  If you would like to object to our disclosure about your health information in either of the
  situations listed above, please contact our agency Privacy Official listed in this Notice for
  consideration of your objection.
  Disclosure of Your Health Information That Requires Your Authorization
  Majestic Hearing and Tinnitus Centers LLC will not disclose your health information without your
  authorization except as allowed or required by state or federal law. For all other disclosures, we
  will ask you to sign a written authorization that allows us to share or request your health
  information. Before you sign an authorization, you will be fully informed of the exact information
  you are authorizing to be disclosed/requested and to/from whom the information will be
  disclosed/requested.
  You may request that your authorization be cancelled by informing our agency Privacy Official
  that you do not want any additional health information about you exchanged with a particular
  person/agency. You will be asked to sign and date the Authorization Revocation section of your
  original authorization; however, verbal authorization is acceptable. Your authorization will then
  be considered invalid at that point in time; however, any actions that were taken on the
  authorization prior to the time you cancelled your authorization are legal and binding.
  If you are a minor who has consented to treatment for services regarding the prevention,
  diagnosis and treatment of certain illnesses including: venereal disease and other diseases that
  must be reported to the State; pregnancy; abuse of controlled substances or alcohol; or
  emotional disturbance, you have the right to authorize disclosure of your health information.
  Disclosure of health information to external client advocates will require authorization by you
  and your personal representative if one has been designated. (The following applies to
  substance abuse providers only – “If you are a minor whose parent or guardian has consented
  to your treatment for substance abuse, both you and your parent or guardian must authorize
  disclosure of your health information.”)
  Your Rights Regarding Your Health Information
  You have the following rights regarding your health information as created and maintained by
  this agency.
  Right to receive a copy of this Notice
  You have the right to receive a copy of Majestic Hearing and Tinnitus Centers LLC’s Notice of
  Privacy Practices. At your first treatment encounter with this agency, you will be given a copy of
  this Notice and asked to sign an acknowledgement that you have received it. In the event of
  emergency services, you will be provided the Notice as soon as possible after emergency
  services have been provided.
  In addition, copies of this Notice have been posted in several public areas throughout this
  agency, as well as on the Majestic Hearing and Tinnitus Centers LLC’s Internet web site at
  (majestichac.com). You have the right to request a paper copy of this Notice at any time from
  our agency Admissions Officer or our agency Privacy Official.
  Right to request different ways to communicate with you.
  You have the right to request to be contacted at a different location or by a different method. For
  example, you may request all written information from this agency be sent to your work address
  rather than your home address. We will agree with your request as long as it is reasonable to
  do so; however, your request must be made in writing and forwarded to our agency Privacy
  Official.
  Right to request to see and copy your health information
  Whether you are a minor, incompetent adult or competent adult, you have the right to request to
  see and receive a copy of your health information in medical, billing and other records that are
  used to make decisions about you. Your request must be in writing and forwarded to our
  agency Privacy Official. You can expect a response to your request within 30 days. If your
  request is approved, you may be charged a fee to cover the cost of the copy.
  Instead of providing you with a full copy of your health information record, we may give you a
  summary or explanation of your health information, if you agree in advance to that format and to
  the cost of preparing such information.
  Your request may be denied by your physician or a professional designated by our agency
  director under certain circumstances. If we do deny your request, we will explain our reason for
  doing so in writing and describe any rights you may have to request a review of our denial. In
  addition, you have the right to contact our agency Privacy Official to request that a copy of your
  health information be sent to a physician or psychologist of your choice.
  Whenever you have a personal representative who consented to your treatment, the personal
  representative has the same rights to request to see and copy your health information.
  Right to request amendment of your health information
  You have the right to request changes in your health information in medical, billing and other
  records used to make decisions about you. If you believe that we have information that is either
  inaccurate or incomplete, you may submit a request in writing to our agency Privacy Official and
  explain your reasons for the amendment. We must respond to your request within 30 days of
  receiving your request. If we accept your request to change your health information, we will add
  your amendment but will not destroy the original record. In addition, we will make reasonable
  efforts to inform others of the changes, including persons you name who have received your
  health information and who need the changes.
  We may deny your request if:
• The information was not created by this agency (unless you prove the creator of the
  information is no longer available to change the information);
• The information is not part of the records used to make decisions about you;
• We believe the information is correct and complete; or
• Your request for access to the information is denied.
  If we deny your request to change your health information, we will explain to you in writing the
  reasons for denial and describe your rights to give us a written statement disagreeing with the
  denial. If you provide a written statement, the statement will become a permanent part of your
  record. Whenever disclosures are made of the information in question, your written statement
  will be disclosed as well.
  Right to request a listing of disclosures we have made
  You have a right to a written list of disclosures of your health information. The list will be
  maintained for at least six years for any disclosures made after April 14, 2003. This listing will
  include the date of the disclosure, the name (and address, if available) of the person or
  organization receiving the information, a brief description of the information disclosed and the
  purpose of the disclosure.
  This agency is not required to include the following on the list of disclosures:
• Disclosure for your treatment;
• Disclosure for billing and collection of payment for your treatment;
• Disclosures related to our health care operations;
• Disclosures that you authorized;
• Disclosures to law enforcement when you are in their custody; or
• Disclosures made to individuals involved in your care.
  Your first request for a listing of disclosures will be provided to you free of charge. However, if
  you request a listing of disclosures more than once in a 12 month period, you may be charged a
  reasonable fee. We will inform you of the cost involved and you may choose to withdraw or
  modify your request at that time, before any costs are incurred.
  Right to request restrictions on uses and disclosures of your health information
  You have the right to request that we limit our use and disclosure of your health information for
  treatment, payment and health care operations. You also have the right to request a limit on the
  health information we disclose about you to your next of kin or someone who is involved in your
  care. ( Example: you could ask that we not disclose information about your family history of
  heart disease.) We will provide you with a form to document your request.
  We will make every attempt to honor your request but are not required to agree to such request.
  However, if we do agree, we must follow the agreed upon restriction (unless the information is
  necessary for emergency treatment or unless it is a disclosure to the U.S. Secretary of the
  Department of Health and Human Services).
  You may cancel the restrictions at any time and we will ask that your request be in writing. In
  addition, this agency may cancel a restriction at any time, as long as we notify you of the
  cancellation.
  Violations/Complaints
  (Applicable to substance abuse providers – “Violation of the Federal law and regulations relative
  to a substance abuse program is a crime. Suspected violations may be reported to our agency
  Privacy Official who will report the violation to appropriate authorities in accordance with Federal
  regulations.”)
  If you believe we have violated your privacy rights, or if you want to file a complaint regarding
  our privacy practices, you may contact our agency Privacy Official. Contact information is as
  follows:
  Majestic Hearing and Tinnitus Centers LLC Privacy Official: Kaycee Magee
  Agency Address: 124 Joel Wright Dr. Hendersonville, NC 28792
  Agency Phone Number: (888)537-3280
  Agency email address: majestichac@gmail.com
  You may also send a written complaint to the United States Secretary of the Department of
  Health and Human Services. Contact information is as follows:
  Office for Civil Rights
  U.S. Department of Health and Human Services
  Atlanta Federal Center, Suite 3B70
  61 Forsyth Street, S.W.
  Atlanta, GA 30303-8909
  Voice Phone: (404) 562-7886
  FAX: (404) 562-7881
  TDD: (404) 331-2867
  If you file a complaint, we will not take any action against you or change the quality of health
  care services we provide to you in any way.
  Legal References
  Primary Federal and State laws and regulations that protect the privacy of your health
  information are listed below.
  Confidentiality of Alcohol and Drug Abuse Patient Records – 42 U.S.C. 290dd-3 and 42 U.S.C.
  290ee-3 for Federal laws and 42 CFR Part 2 for Federal regulations.
  Health Insurance Portability and Accountability Act (HIPAA), Administrative Simplification,
  Privacy of Individually Identifiable Health Information – 42 U.S.C. 1320d-1329d-8 and 42 U.S.C.
  1320d-2(note) for Federal laws and 45 CFR Parts 160 and 164 for Federal regulations.
  NC General Statutes – Chapter 122C, Article 3 (Client’s Rights and Advance Instruction), Part 1
  (Client’s Rights). Chapter 90 (Medicine and Allied Occupations), Article 1 (Practice of
  Medicine).
  NC Administrative Code – 10 NCAC 18 D (Confidentiality Rules)