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Section VI |
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Section VI |
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VI.
Your Right Regarding Your Protected Health Information
You have the following rights concerning the use or
disclosure of your protected health information that we create or
that we may maintain on our premises:
You have the right to request that we limit how we use or disclose your
protected health information for treatment, payment or health care
operations. You also have the right to request a limit on the health
information we disclose about you to someone who is involved in your
care or the payment for your care or services. For example, you
could request that we not disclose to family members or friends
information about a medical treatment you received. Should you wish a restriction placed on the use and disclosure of your
protected health information, you must submit such request in
writing. (Note: You may submit such request using our Request
To Restrict The Use and Disclosure of Protected Health Information
form. Copies of this form are available from our privacy officer.)
The name, address, and telephone number of the person to whom the
request is to be submitted is listed on the last page of this
document. We are not required to agree to your restriction request.
However, should we agree, we will comply with your request not to
release such information unless the information is needed to provide
emergency care or treatment to you.
You have the right to inspect and copy your health information, such as
your medical and billing records that we use to make decisions about
your care and services. In order to inspect and/or copy your health
information, you must submit a written request to us. If you request
a copy of your medical information, we may charge you a reasonable
fee for the paper, labor, mailing, and/or retrieval costs involved
in filing your requests. We will provide you with information
concerning the cost of copying your health information prior to
performing such service. The name, address, and telephone number of
the person to whom you may file your request is listed on the last
page of this document. You may submit your requests on our Request
for Inspection/Copy of Protected Health Information form. Copies
of these forms are available in the business office. We will respond within thirty (30) days of receipt of such requests.
Should we deny your request to inspect and/or copy your health
information, we will provide you with written notice of our reasons
of the denial and your rights for requesting a review of our denial.
If such review is granted or is required by law, we will select a
licensed health care professional not involved in the original
denial process to review your request and our reasons for denial. We
will abide by the reviewer’s decision concerning your
inspection/copy requests. You may submit your denial review requests
on our Denial of Inspection/Copy of Protected Health Information
form. Copies of these forms are available in the business office.
You have the right to request that your health information be amended or
corrected if you have reason to believe that certain information is
incomplete or incorrect. You have the right to make such requests of
us for as long as we maintain/retain your health information. Your
requests must be submitted to us in writing. We will respond within
sixty (60) days of receiving the written request. If we approve your
request, we will make such amendments/corrections and notify those
with a need to know of such amendments/corrections. We may deny your request if: a.
Your request is not submitted in writing; b.
Your
written request does not contain a reason to support your request; c.
The information was not created by us, unless the person or entity that
created the information is no longer available to make the
amendment; d.
It
is not a part of the health information kept by or for our facility; e.
It is not part of the information which you would be permitted to
inspect and copy; and/or f.
The information is already accurate and complete. If your request is denied, we will provide you with a written
notification of the reason(s) of such denial and your rights to have
the request, the denial, and any written response you may have
relative to the information and denial process appended to your
health information. The name, address, and telephone number of the person to whom you may
file your request is listed on the last page of this document. You
may submit your amendment/correction requests on our Request for
Amendment/Correction of Protected Health Information form.
Copies of these forms are available in the business office.
You have the right to request that we communicate with you about your
health matters in a certain way or at a certain location. For
example, you may request that we not send any health information
about you to a family member’s address. We will agree to your
request as long as it is reasonably easy for us to do so. You are
not required to reveal nor will we ask the reason for your request.
To request confidential communications you must: a.
Notify us in writing; b.
Indicate
what information you wish to limit; c.
Indicate whether or not you wish to limit or restrict our use or
disclosure of such information; and d.
Identify
to whom the restrictions apply (e.g., which family member(s),
agency, etc). The name, address, and telephone number of the person to whom you may
file your request is listed on the last page of this document. You
may submit your requests on our Request for Restriction of
Confidential Communications form. Copies of these forms are
available in the business office.
You have the right to request that we provide you with a listing of
when, to whom, for what purpose, and what content of your protected
health information we have released over a specified period of time.
This accounting will not include any information we have made for
the purposes of treatment, payment, or health care operations or
information released to you, your family, or the facility directory,
disclosures made for national security purposes, or any releases
pursuant to your authorization. Your request must be submitted to us in writing and must indicate the
time period for which you wish the information (e.g., May 1, 2003
through August 31, 2005). Your request may not include releases for
more than six (6) years prior to the date of your request and
may not include releases prior to April 14, 2003. Your
request must indicate in what form (e.g., printed copy or email) you
wish to receive this information. We will respond to your request
with sixty (60) days of the receipt of your written request. Should
additional time be needed to reply, you will be notified of such
extension. However, in no case will such extension exceed thirty
(30) days. The first accounting you request during a twelve (12)
month period will be free. There may be a reasonable fee for
additional requests during the twelve (12) month period. 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. The name, address, and telephone number of the person to whom you may
file your request is listed on the last page of this document. You
may submit your requests on our Request for an Accounting of
Disclosures of Protected Health Information form. Copies of
these forms are available in the business office.
You have the right to receive a paper copy of this notice even though
you may have agreed to receive an electronic copy of this notice.
You may request a paper copy of this notice at anytime or you may
obtain a copy of this information from our website (as applicable).
The name, address, and telephone number of the person to whom you
may obtain a paper copy of this notice is listed on the last page of
this document.
© 2003-2005
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