The Americans with Disabilities Act (ADA) is a broad civil rights act prohibiting discrimination against individuals with disabilities. Under title III of the ADA, discrimination against individuals with disabilities in public accommodations, including hospitals and doctor's offices, is prohibited. The Department of Justice (DOJ) promulgated regulations under title III requiring places of public accommodation to provide "auxiliary aids and services" to individuals with disabilities unless they are able to prove such services would be unduly burdensome. Auxiliary aids may include qualified interpreters as well as note takers, video remote interpreting (VRI) services, or real-time computer-aided transcription services. The new regulations issued under title III on July 26, 2010, address several issues including the application of rights to effective communication by companions who are individuals with disabilities, the use of video remote interpreting (VRI) services, and when an accompanying adult or child may be used as an interpreter. The auxiliary aid requirement articulated by the DOJ interprets the broad nondiscrimination language of the ADA and requires effective communication, but neither the statute nor the regulations explicitly state when doctors or hospitals must provide hearing impaired patients with interpreters. As a result, the answer as to whether doctors or hospitals must provide interpreters for hearing impaired individuals is dependent on the particular circumstances surrounding the patient's case. Judicial decisions give some guidance on when an interpreter must be provided in particular factual situations. Title III of the ADA provides that "[n]o individual shall be discriminated against on the basis of disability in the full and equal enjoyment of the goods, services, facilities, privileges, advantages, or accommodations of any place of public accommodation by any person who owns, leases (or leases to), or operates a place of public accommodation." Discrimination is further described as including "a failure to make reasonable modifications in policies, practices, or procedures when such modifications are necessary to afford such goods, services, facilities, privileges, advantages, or accommodations to individuals with disabilities." Public accommodations are exempted from providing these special provisions when they "can demonstrate that making such modification would fundamentally alter the nature of such goods, services, facilities, privileges, advantages, or accommodations." The definition of public accommodation specifically includes the "professional office of a health care professional" and hospitals. On July 26, 2010, the 20 th anniversary of the passage of the ADA, the Department of Justice (DOJ) issued final rules amending the existing regulations under ADA title II (prohibiting discrimination against individuals with disabilities by state and local governments) and ADA title III (prohibiting discrimination against individuals with disabilities by places of public accommodations). These new regulations contain detailed sections on communications. Like the previous regulations, the new regulations require that public entities and public accommodations furnish appropriate aids and services when necessary to ensure effective communication with an exception regarding fundamental alterations or undue burdens. More specifically, the title III regulations state that public accommodations do not have to provide auxiliary aids if such measures would "fundamentally alter the nature of the goods, services, facilities, privileges, advantages, or accommodations being offered or would result in an undue burden, i.e., significant difficulty or expense." In determining whether an action poses an undue burden, the regulations require the consideration of several factors, including the nature and cost of the action, the overall financial resources of the site, the geographic separateness and the administrative or fiscal relationship of the site or sites in question to a parent corporation, the overall financial resources of the parent corporation, and the type of operation or operations of any parent corporation or entity. When a particular auxiliary aid would cause an undue burden, the public accommodation must provide alternative assistance so that the individual can take full advantage of the services and goods offered. Unlike the previous regulations, the new regulations specifically extend the requirement for effective communication to companions who are individuals with disabilities. DOJ noted in its comments on the new regulations that this was a particularly important issue. Effective communication with companions is particularly critical in health care settings where miscommunication may lead to misdiagnosis and improper or delayed medical treatment. The Department has encountered confusion and reluctance by medical care providers regarding the scope of their obligation with respect to such companions. Effective communication with a companion is necessary in a variety of circumstances. For example, a companion may be authorized to make health care decision on behalf of the patient or may need to help the patient with information or instructions given by hospital personnel. A companion may be the patient's next-of-kin or health care surrogate with whom the hospital must communicate about the patient's medical condition. The new regulations also indicate that the type of auxiliary aid or service necessary for effective communication varies depending on the circumstance. The new title III regulations specifically state that "[a] public accommodation should consult with individuals with disabilities whenever possible to determine what type of auxiliary aid is needed to ensure effective communication, but the ultimate decision as to what measure to take rests with the public accommodation, provided that the method chosen results in effective communication." The term "auxiliary aid" is defined to include "qualified interpreters on site or through video remote interpreting (VRI) services, notetakers, real-time computer-aided transcription services, written materials; exchange of written notes ... or other effective methods of making aurally delivered materials available to individuals who are deaf or hard of hearing." The new regulations added video remote services (VRI) as an example of an auxiliary aid that may provide effective communication. The new regulations specifically state that when VRI is used it must provide real-time, full-motion video and audio over a dedicated high-speed, wide-bandwidth video or wireless connection that does not produce lags, choppy, blurry or grainy images or irregular pauses in communications; a sharply delineated image that is large enough to display the interpreter's face, arms, hands, and fingers and the participating individual's face, arms, hands, and fingers; and a clear, audible transmission of voices. In addition, a public accommodation that uses VRI must provide adequate training to users of the technology and other involved individuals. The new regulations also discuss when a family member or a friend may be used as an interpreter. Generally, a public accommodation is not to rely on an adult who accompanies an individual with a disability to interpret for the individual. However, there are some exceptions including an emergency involving an imminent threat to safety or welfare, and where the individual with a disability specifically requests that the accompanying adult interpret and the accompanying adult agrees. A minor child may not be used to interpret except in an emergency situation. As the regulations indicate, there is no absolute requirement that an interpreter be provided in a particular situation. However, in order to comply with the ADA, auxiliary aids must provide effective doctor-patient communication. In Mayberry v. Van Valtier, the court held that a deaf Medicare patient was entitled to a trial on her claim that her doctor violated the ADA. In this case, the doctor had communicated with the patient for several years mostly by exchanging notes or using the patient's children as sign interpreters and on one occasion had noted in the patient's file that her back pain was higher than she had originally thought and that this misunderstanding was "probably due to poor communication." The patient, Mrs. Mayberry, requested that the doctor provide an interpreter for a physical examination. The doctor complied but following the examination wrote a letter to the interpreter, with a copy to the patient, stating that she would not be able to use the interpreter's services again and that "I really can't afford to take care of Mrs. Mayberry at all." The doctor characterized the letter as a protest against what was perceived as an unfair law. The court found that the allegations made by the patient were sufficient to reject a motion for summary judgment and ordered the case to proceed to trial. Subsequently, a judgment was rendered in favor of the doctor but there is no record of a written opinion. In Aikins v. St. Helena Hospital , another district court examined arguments concerning effective communication and denied summary judgment to the hospital and doctor. Elaine Aikins, a hearing impaired individual, and the California Association of the Deaf (CAD) alleged that St. Helena Hospital and Dr. James Lies failed to communicate effectively with Mrs. Aikins during her now deceased husband's medical treatment. Instead of an interpreter, the hospital provided Mrs. Aikins with an ineffective finger speller. Allegedly Mrs. Aikins was unable to effectively communicate with Dr. Lies or other hospital staff until her daughter became available to interpret, an argument that was supported by the doctor's mistaken impression concerning how long the patient had been without CPR. Mrs. Aikins and the CAD alleged that Dr. Lies and St. Helena Hospital violated both the ADA and the Rehabilitation Act. Dr. Lies maintained that the Rehabilitation Act was inapplicable and St. Helena asserted that it complied with both the ADA and Rehabilitation Act. Although the ADA claims were dismissed due to lack of standing, the court noted that adequate medical treatment is not a defense to a claim that a defendant failed to provide effective communication under the Rehabilitation Act of 1973. "Mrs. Aikins's claims relate to her exclusion from meaningful participation in the decisions affecting her husband's treatment, not to the appropriateness of the treatment itself." Citing Aikins , the court in Naiman v. New York University found that a physician's effectiveness in providing medical treatment to a hearing impaired patient does not negate an ineffective communication claim under the ADA. Mr. Alec Naiman, who is hearing impaired, was admitted on several occasions to New York University Medical Center, one of many medical facilities operated by New York University. On each occasion Mr. Naiman requested an interpreter in order to "effectively participate in his treatment" and communicate with hospital staff. With the exception of one visit, the center failed to provide one in a timely manner or did not provide an interpreter at all.