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:
  • 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 associated supplies.
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 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.



How We May Use and Disclose Health Information About You (1/4)
Special Situations (2/4)
Other Uses and Disclosures of Health Information (3/4)
Changes to this Notice (4/4)

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