Other uses and disclosures of your PHI will be made only upon receiving your written authorization.  You may revoke an authorization at any time by providing written notice to Covered Entity that you wish to revoke an authorization.  Covered Entity will honor a request to revoke as of the day it is received and to the extent that Covered Entity has not already used or disclosed your PHI in good faith with the authorization.

There is a potential for any information disclosed pursuant to this authorization to be subject to re-disclosure by the recipient and, therefore, no longer protected to the same extent as such health information was protected by law while solely in the possession of the health care entity. 

YOUR INDIVIDUAL RIGHTS IN RELATION TO YOUR PHI

Right to Request Restrictions on Uses and Disclosures:

You have the right to request that Covered Entity limit its uses and disclosures of PHI in relation to treatment, payment and health care operations, except for uses or disclosures required by law.  You also have the right to request that Covered Entity restrict the use of disclosure of your PHI to family members or personal representatives.  Any such request must be made in writing to the Privacy Contact listed in this Notice and must state the specific restriction requested and to whom that restriction would apply.

Pursuant to federal law, if you request that we not share PHI with your insurance company, Covered Entity will accept that request but only if you pay in full for the service rendered.

Right to Receive Confidential Communications of Your Health Information:

You have the right to request that communications involving PHI be provided to you at an alternative location or by an alternative means of communication.  Covered Entity will accommodate any reasonable request if the normal method of disclosure would endanger you and that danger is stated in your request.  Any such request must be made in writing to the Privacy Contact listed in this Notice.

Right to Access Your Protected Health Information:

You have the right to inspect and copy your PHI that is contained in a “designated record set” for as long as Covered Entity maintains your PHI.  A designated record set contains claim information, premium and billing records and any other records that Covered Entity has created in caring for you. You have the right to be provided with copies of health and medical records in electronic form if Covered Entity maintains health records in that format and the documents are readily producible in such format. Federal law prohibits you from having access to psychotherapy notes or information compiled for civil, criminal, or administrative proceedings.  Covered Entity may deny your right to access in a few limited circumstances, and will provide you with a written explanation of the reason for denial. You may appeal such a denial in limited scenarios.  Requests for access to your PHI should be made in writing to the Privacy Contact listed in this Notice. 

Right to Request Release of Your Protected Health Information: 

You have the right to give permission for your Protected Health Information to be disclosed for communicating results, findings and care decisions to your family members and others. If you wish to make such a disclosure, you must communicate the Name, Relationship, and contact information to the Privacy Contact listed in this Notice to ensure it is documented.

Right to Amend your Protected Health Information:

You have the right to request that PHI in a designated record set be amended for as long as Covered Entity maintains the PHI.  Covered Entity may deny your request for amendment if it determines that the PHI was not created by Covered Entity, is not part of the designated record set, is not information that is available for inspection, or that the PHI is accurate and complete.  If your request for amendment is declined, you have the right to have a statement of disagreement included with the PHI and Covered Entity has a right to include a rebuttal to your statement.  Requests for amendment of your PHI should be made in writing to the Privacy Contact listed in this Notice.

Right to Receive an Accounting of Disclosures of your PHI:

You have the right to receive an accounting of all disclosures of your PHI that Covered Entity has made, if any, for reasons other than disclosures for treatment, payment and health care operations, and disclosures made to you or your personal representative. Your right to an accounting of disclosures cannot exceed a period of six (6) years before the date of your request.  Requests for an accounting of disclosures of your PHI must be made in writing to the Privacy Contact listed in this Notice.  

Right to Receive Notice Upon a Breach: 

In the event of a breach of unsecured PHI, you have the right to be notified by Covered Entity. This right applies only if the PHI was not reasonably secured. 

Right to Receive a Paper Copy of This Notice:

If you receive this notice electronically, you have the right to receive a paper copy upon request.  Requests for a paper copy of this Notice should be made in writing to the Privacy Contact listed in this Notice.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with Covered Entity or with the Secretary of Health and Human Services.  Complaints should be filed in writing with the Privacy Contact listed in this Notice.  Our office will not retaliate against you for filing a complaint.

PRIVACY OFFICER

Should you have any questions, requests, comments, or complaints you may direct all inquiries to our Privacy Contact.

Privacy Officer Contact Information: