SECTION D - YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION

You have the following rights regarding the medical information that we maintain about you:

Requesting Restrictions: You have the right to request a restriction in our use or disclosure of your medical information for treatment, payment or health care operations. Additionally, you have the right to request that we limit our disclosure of your medical information to individuals involved in your care or the payment for your care, such as family members and friends.

We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your medical information, you must make your request in writing to the Privacy Officer. Your request must describe in a clear and concise fashion: (1) the information you wish restricted: (2) whether you are requesting to limit our practice’s use, disclosure, or both; and (3) to whom you want the limits to apply.

Confidential Communications: You have the right to request that the covered entity communicate with you about your health and related issues in a particular manner, or at a certain location. For instance, you may ask that we contact you by mail, rather than by telephone, or at home rather than work.

In order to request a type of confidential communication, you must make a written request to the Privacy Officer specifying the requested method of contact, or the location where you wish to be contacted. The covered entity will accommodate reasonable requests. You are not required to give a reason for your request.

Inspection and Copies: You have the right to inspect and obtain a copy of the medical information that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to the Privacy Officer in order to inspect and /or obtain a copy of your medical information. The covered entity may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. The covered entity may deny your request to inspect and/or copy in certain limited circumstances. However, you may request a review of our denial. Reviews will be conducted by another licensed health care professional chosen by us, not by the person who denied your request.

Amendment: You may ask the covered entity to amend your medical information if you believe it is incorrect or incomplete. You may request an amendment for as long as the information is kept by the covered entity. To request an amendment, your request must be made in writing and submitted to the Privacy Officer. You must provide us with a reason that supports your request for amendment. The covered entity may deny your request if you fail to submit your request in writing or the request does not include a reason. Also, we may deny your request if you ask us to amend information that is:

• accurate and complete
• not part of the medical information kept by or for the organization
• not part of the medical information which you would be permitted to inspect and copy; or
• not created by the covered entity, or unless the individual that created the information is no longer available to amend the information.

Accounting of Disclosures: You have the right to request an accounting of disclosures. An accounting of disclosures is a list of certain disclosures our organization has made of your medical information. In order to obtain an accounting of disclosures, you must submit your request in writing to the Privacy Officer. A request for an accounting of disclosures must state a time period that may not be longer than six (6) years and may not include dates before April 14, 2003. The first list you request within a 12-month period is free of charge, but the covered entity may charge you for additional lists within the same 12-month period. The covered entity will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.

Right to a Paper Copy of This Notice: You have the right to obtain a paper copy of this Notice at any time. You will automatically receive a copy of this Notice during the Registration process upon your first visit to the Hospital. After your first visit, a copy of our Notice of Privacy Practices will be available to you if you wish to receive one.

Right to Provide an Authorization for Other Uses and Disclosures: The covered entity will obtain your written authorization for uses and disclosures that are not identified by this notice or are not permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your medical information may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your medical information for the reasons described in the authorization. Of course, we are unable to take back any disclosures that we have already made with your authorization.

Right to File a Complaint: If you believe your privacy rights have been violated, you may file a complaint with the covered entity or with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

To file a complaint with the covered entity, contact the Privacy Contact listed here.