‣ Right to Amend . If you feel that medical 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 for as long as the information is kept by or for the entity .
To request an amendment , your request must be made in writing on the required form and submitted to the Entity Privacy Coordinator . In addition , you must provide a reason that supports your request .
We may deny your request for an amendment if it 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 :
• was not created by us , unless the person or entity that created the information is no longer available to make the amendment ;
• is not part of the medical information kept by or for the entity ;
• is not part of the information which you would be permitted to inspect and copy ; or
• 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 certain disclosures we made of medical information about you .
To request this list or accounting of disclosures , you must submit your request in writing on the required form to the Entity Privacy Coordinator . Your request must state a time period which may not be longer than six years . 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 cost 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 Restriction . You have the right to request a restriction or limitation on the medical 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 medical information we disclose about you to someone who is involved in your care or the payment for your care , 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 do agree , we will comply with your request unless the information is needed to provide you emergency treatment .
To request restrictions , you must make your request in writing on the required form to the Entity Privacy Coordinator . In your request , you must tell us ( 1 ) what information you want to limit ; ( 2 ) whether you want to limit our use , disclosure , or both ; and ( 3 ) to whom you want the limits to apply , for example , disclosures to your spouse .
‣ Right to Request That Health Information Pertaining to Services Paid Out of Pocket Not Be Sent to Insurance or Other Health Plans . In some instances , you may choose to pay for a healthcare item or service out of pocket , rather than submit a claim to your insurance company . You have the right to request that we not submit your health information to a health plan or your insurance company , if you , or someone on your behalf , pay for the treatment or service out of pocket in full . To request this restriction , you must make your request in writing on the required form to the Entity Privacy Coordinator prior to the treatment or service . In your request , you must tell us ( 1 ) what information you want to restrict ( 2 ) and to what health plan the restriction applies .
‣ 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 . For example , you can ask that we only contact you at work or by mail .
To request confidential communications , you must make your request in writing on the required form to the Entity Privacy Coordinator . 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 Revoke Authorization . You have the right to revoke your authorization to use or disclose your medical information except to the extent that action has already been taken in reliance on your authorization .
‣ 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 this Notice electronically , you are still entitled to a paper copy of this Notice .
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