Guest Notice- Privacy Policy

Dear Valued Guest,

We look forward to your upcoming appointment with us.

In becoming our patient, you are agreeing to receive text message(s) from our office regarding your appointments, rescheduling, etc. Please let us know if you would NOT like us to contact you this way!

Please call us at 843-703-5083 with any questions or concerns. If you have any documents (e.g., prior hearing test results, medical records of ear infections/tubes) that you would like to share with us, you may send via email (*unsecured, not HIPAA compliant*) with them attached or you may bring them to your visit. Email empireofficeassist@gmail.com

As we are a one provider office, it is important that you keep your appointment or reschedule your appointment at your earliest convenience should anything come up. A “No Show Fee” will be applied to your account if an appointment has been missed. This fee will not be applied if the appointment has been rescheduled or moved to a later time. The “No Show Fee” will need to be paid prior to any future testing, hearing aid checks/cleanings, ear wax cleanings, etc.

Thank you for your understanding and we look forward to helping you soon!

 
Acknowledgement of Receipt of Notice (HIPAA and Financial Policy)

Thank you for choosing Empire Audiology! Our primary mission is to deliver the best and most comprehensive hearing care available. An important part of our mission is to make the cost of optimal care and hearing aids as easy and manageable as possible for our patients by offering several payment options. Payment options include Cash, Check, and Debit/Credit Card. We apologize for the inconvenience, but we do not accept Apple/Samsung Pay, Cash App, Venmo, Pay Pal, Zelle, etc.

Please note: Empire Audiology requires payment at the time of your visit for any services provided unless third party coverage has been pre-determined, or services are covered by an established care plan. We will file diagnostic testing and procedures to your insurance. For patients with insurance, we are happy to work with your carrier to maximize our benefit and directly bill them for reimbursement for your hearing aids and other services.

For Medicare recipients, a referral from the patient’s Primary Care Physician is necessary for Medicare to cover the cost of medically necessary hearing tests. Medicare categorically excludes all non-surgical hearing management; therefore, does not pay for hearing aids, any hearing aid services, or auditory rehabilitation services.

For any equipment purchases, a down payment of 50% will be required at the time of the order or otherwise specified. Payment in full is expected at the time of fitting unless insurance reimbursement is anticipated and verified prior to the date of the fitting.

Prior authorization and verification of benefits from insurance companies are not binding, nor are they a guarantee of payment. Patients should be prepared to cover the full cost of services and equipment provided, or any balance remaining after insurance reimbursement. Insurance benefits must be reviewed and verified by Empire Audiology staff prior to the fitting to avoid payment in full at that time. Alternatively, equipment can be paid for in full and filed for reimbursement directly to the patient.

We would be happy to complete the filing on your behalf if provided with all of the necessary information. In the event of overpayment or insurance reimbursement greater than anticipated, refunds will be processed after the clinic’s receipt of reimbursement.

Empire Audiology charges $25 for returned checks.

Empire Audiology charges $25 for any “No Showed” or missed appointments if not canceled/rescheduled more than 24 hours in advance. The “No Showed” payment must be paid before further appointments may be conducted.

Verbal abuse or inappropriate physical contact of any sort that is directed towards the Empire Audiology staff will not be tolerated regarding any facet of your treatment and care. Patients or patient representatives who are abusive will be dismissed without a refund.

1.     Financial Policy:

I agree and understand.

2.     I wish to receive a copy of the Financial Policy:

Yes.

3.     I understand that healthcare has an associated cost. Please check each to indicate that you agree:

Empire Audiology will bill my insurance on my behalf if I request that they do so. Ultimately, I am responsible for the cost of my care that is not covered by my insurance. ____ I agree to pay the expected amount due at the time or service and any balance sent to me within 3 months. ____ I agree that I will make full payment at the time of the receipt of invoices for services rendered. ____ Medical Claims will be filed with my insurance carrier as a courtesy, and I authorize the release of information requested to process insurance claims. However, should my insurance deny the claim for any reason, I understand that I will be responsible for my bill. ____ I agree that I am financially and legally responsible for all charges incurred, regardless of insurance coverage.

 The Department of Health and Human Services Privacy Rule under HIPAA (Health Insurance Portability and Accountability Act) in compliance with the September 23, 2013, Omnibus Rule, this “Notice of Privacy” describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment, health care operations, or any other purposes that are permitted by the law. It also describes your rights to access and control your PHI.

 “Protected Health Information” is information about you, including demographic information, that may identify you and that relates to your past, present, and future physical or mental health or condition and related health care services.

 Uses and Disclosures of PHI: Your PHI may be used and disclosed by your Healthcare Provider, our office staff, and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to process your health care bills, to support the operation of the Healthcare Provider’s practice, and any other use required by law.

 Treatment: We will use and disclose your PHI to provide, coordinate, or manage your healthcare and any related services. This includes the coordination or management of your healthcare with a third party. For example, your PHI may be provided to a Healthcare Provider to whom you have been referred or whom referred to you to ensure that that Healthcare Provider has the necessary information to diagnose or treat you.

 Payment: Your PHI will be used, as needed, to obtain payment for your healthcare services. For example, obtaining approval for hearing aids or hearing testing may require that your relevant PHI be disclosed to the healthcare plan to obtain approval for such services.

Healthcare Operations: We respect, secure, and protect the privacy of our patients’ PHI. When appropriate and necessary, we provide the minimum necessary to healthcare professionals in need of your healthcare information and treatment. We have indirect treatment relationships with hearing aid and earmold companies and disclose PHI for purposes of payment or healthcare products.

 We may use or disclose your PHI in the following situations without your authorization. The aforementioned situations include: Public Health issues as required by law; Communicable diseases; Health Oversight; Food and Drug Administration requirements; Legal Proceedings; Military Activity and National Security; Workers’ Compensation; Hearing Aid Manufacturers; Other Permitted and Required Uses and Disclosures: other disclosures will be made only with your consent, authorization, or opportunity to object unless required by law.

 Your Privacy Rights

The following is a statement of your rights with respect to your PHI.

 I.                You have the right to inspect and request copies of your PHI. We support your full access to your personal medical records. You may request transmission of your medical records to a designated party in any form, hard copy or electronically. In such cases, we will verify the identity of the individual making the request and take reasonable steps to ensure that the email address or the fax number of the recipient is correct. However, under federal law, you may not inspect nor copy the following records: information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and PHI that is subject to law that prohibits access to protected health information.

II.              You have the right to request a restriction of your PHI. This means you may ask us not to use or disclose any part of our PHI for the purposes of treatment, payment, or healthcare operations. You may also request that any part of your PHI 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 that specific restriction requested and to whom you want the restriction to apply. Our Healthcare Provider(s) are not required to agree to a restriction that you may request. If your Healthcare Provider believes it is in your best interest to permit use and disclosure of your PHI, your PHI will not be restricted. You then have the right to use another Healthcare Provider. It is your right to opt out of the use of your PHI for marketing purposes by Empire Audiology or its suppliers (i.e., Hearing Aid Manufacturers, etc.).

III.            You may request transmission of your medical records to a designated party in any form, hard copy or electronically. In such cases, we will verify the identity of the individual making the request and take reasonable steps to ensure that the email address or fax number of the recipient is correct. Upon request, you have the right to obtain a paper copy of this notice from us, even if you have agreed to accept this notice alternatively (i.e., electronically). You may have the right to have your Healthcare Provider amend your PHI. 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 of disagreement 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 PHI. We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.

IV.           You may complain to our Practice Manger or to the Secretary of Health and Human Servies if you believe our privacy right have been violate by us. 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/notice, please asl to speak with our HIPAA Compliance Officer in person or by phone at 843-703-5083. You may refuse consent to the use or disclosure of your PHI. Under this law, we have the right to refuse treatment should you choose not to disclose your PHI.

 1.     Department of Health and Human Services Privacy Rule under HIPAA (Health Insurance Portability and Accountability Act) statement from Empire Audiology:

I accept the HIPAA statement from Empire Audiology.

2.     I wish to receive a paper copy of the Notice of Privacy Rights

Yes   or   No

Privacy Policy

Effective Date: January 22, 2025

Empire Audiology (“we,” “us,” “our”) respects your privacy and is committed to protecting

your personal information. This Privacy Policy explains how we collect, use, and share

information when you opt in to receive SMS messages from us.

Information We Collect

When you opt in to receive SMS messages, we collect:

• Your phone number

• Consent to send SMS messages

How We Use Your Information

We use your information to:

• Send you the SMS messages you’ve opted in to receive

• Provide updates, promotions, or other relevant content based on your preferences

Sharing Your Information

We do not share your phone number or SMS opt-in information with third parties for marketing

purposes.

Your Rights

You can opt out of receiving SMS messages at any time by replying with “STOP” to any

message we send you.

Data Security

We implement reasonable measures to protect your personal information from unauthorized

access or disclosure.

If you have questions or concerns about our privacy practices, contact us at 843.703.5083