Notice of Privacy, p 3 of 4
OTHER USES AND DISCLOSURES OF HEALTH INFORMATIONS
We will not use or disclose your health information for any purpose other
than those identified in the previous sections without your specific, written authorization.
If you give us Authorization to use or disclose health information about you, you may
revoke that Authorization, in writing, at any time. If you revoke your Authorization,
we will no longer use or disclose information about you for the reasons covered by
your written Authorization, but we cannot take back any uses or disclosures already
made with your permission.
In some instances, we may need specific, written authorization from you in order
to disclose certain types of specially protected information such as HIV, substance
abuse, mental health, and genetic testing information.
YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU
You have the following rights regarding health information we maintain about you:
We may deny your request to inspect and/or copy records in certain limited circumstances.
If you are denied copies of or access to health information that we keep about you,
you may ask that our denial be reviewed. If the law gives you a right to have our denial
reviewed, we will select a licensed health care professional to review your request and
our denial. The person conducting the review will not be the person who denied your
request, and we will comply with the outcome of the review.
- Right to Inspect and Copy You have the right to inspect and copy your health
information, such as medical and billing records, that we keep and use to make decisions
about your care. You must submit a written request to Dian Payant, Privacy Officer, in
order to inspect and/or copy records of your health information. If you request a copy
of the information, we may charge a fee for the costs of copying, mailing or other
- Right to Amend If you believe health information we have about you is
incorrect or incomplete; you may ask us to amend the information. You have the right
to request an amendment as long as this office keeps the information.
To request an amendment, complete and submit a MEDICAL RECORD AMENDMENT/CORRECTION FORM to
Dian Payant Privacy Officer.
We may deny your request for an amendment if your request is not in writing or
does not include a reason to support the request. In addition, we may deny your
request if you ask us to amend information that:
- We did not create, unless the person or entity that created the information is no
longer available to make the amendment
- Is not part of the health information that we keep
- You would not be permitted to inspect and copy
- Is accurate and complete
- Right to an Accounting of Disclosures You have the right to request an
"accounting of disclosures." This is a list of the disclosures we made of
medical information about you for purposes other than treatment, payment, health
care operations, and a limited number of special circumstances involving national
security, correctional institutions and law enforcement. The list will also exclude
any disclosures we have made based on your written authorization.
To obtain this list, you must submit your request in writing to Dian Payant Privacy Officer.
It must state a time period, which may be longer that six years and may not include
dates before April 14, 2003. Your request should indicate in what form you want the
list (for example, on paper, electronically). The first list you request within a
12-month period will be free. For additional lists, we may charge you for the costs
of providing the list. We will notify 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 You have the right to request a restriction or
limitation on the health information we use or disclose about you for treatment, payment
or health care operations. You also have the right to request a limit on the health
information we disclose about you or someone who is involved in your care or the payment
for it, like a family member or friend. For example, you could ask that we not use or
disclose information about a surgery you had.
We are not required to agree to your request. If we agree, we will comply
with your request unless the information is needed to provide you emergency treatment
or we are required by law to use or disclose the information.
To request restrictions, you may complete and submit the REQUEST FOR RESTRICTION
ON USE/DISCLOSURE OF MEDICAL INFORMATION to Dian Payant, Privacy Officer.
- Right to Request Confidential Communications You have the right to request that
we communicate with you about medical matters in a certain way or at a certain location. F
or example, you can ask that we only contact you at work or by mail.
To request confidential communications, you may complete and submit the REQUEST FOR
RESTRICTION ON USE/DISCLOSURE OF MEDICAL INFORMASTION AND/OR CONFIDENTIAL COMMUNICATION
to Dian Payant Privacy Officer. We will not ask you the reason for your request.
We will accommodate all reasonable requests. Your request must specify how or
where you wish to be contacted.
- Right to a Paper Copy of This Notice You have the right to a paper copy of
this notice. You may ask us to give you a copy of this notice at any time. Even if you
have agreed to receive it electronically, you are still entitled to a paper copy.
To obtain such a copy, contact Privacy Officer, Dian Payant.