Specialty Pharmacy Welcome Booklet 2025 | Seite 26

payment, or health care operations. These internal uses are permitted under law and are not part of the accounting of disclosures.

To request an accounting of disclosures, you must submit your request in writing on the required form to an Entity Privacy Coordinator. Your request must specify a time period that may not be longer than the six years before the date of your request and should indicate the format in which you would like the list( for example, on paper or electronically). The first accounting you request within a 12-month period will be provided at no charge. For additional lists, we may charge a reasonable, cost-based fee. We will notify you of the cost before the list is prepared, and you may choose to withdraw or modify your request to reduce or avoid the fee.

� Right to Request Restrictions. You have the right to request that we restrict or limit how we use or disclose your health information for treatment, payment, or health care operations. You also have the right to request a limit on your health information we disclose to someone involved in your care or 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 in most circumstances. However, we must agree to your request in two situations:

1. If you ask us not to disclose information about an item or service to a health plan for payment or health care operations purposes and you( or someone else on your behalf) have paid in full for that item or service out of pocket; and

2. If you ask us not to disclose your information to family members or friends involved in your care or payment for your care. If we agree to your request, we will comply with your request unless the information is needed to provide you with emergency treatment or we are required by law to disclose it. If we deny your request, we will tell you why and explain your options.

To request a restriction, you must submit your request in writing on the required form to an Entity Privacy Coordinator. Your request must specify( 1) what information you want to limit;( 2) whether you want to limit our use, disclosure, or both; and( 3) to whom the limits should apply, for example, disclosures to a family member.

� Right to Request That Health Information Pertaining to Services Paid Out of Pocket Not Be Sent to Insurance or Other Health Plans. You may choose to pay for a health care item or service out of pocket rather than submit a claim to your health plan. If you do so, you have the right to request that we not disclose information about that item or service to your health plan for payment or health care operations purposes.

To request this restriction, you must make your request in writing on the required form to an Entity Privacy Coordinator before the treatment or service. Your request must specify( 1) what information you want limited, and( 2) which health plan should not receive the information. We will agree to your request if the disclosure would otherwise be made for payment or health care operations purposes and is not required by law.

This restriction applies only to the specific item or service that was paid for in full out of pocket and does not affect disclosures to your health care providers for treatment or when the law requires us to make a disclosure.

� Right to Request Confidential Communications. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. For example, you may ask we contact you only at work, by mail, or at a certain address or telephone number.

To request confidential communications, you must make your request in writing to an Entity Privacy Coordinator and specify how or where you wish to be contacted. We will not ask you the reason for your request, and we will accommodate all reasonable requests. We will always accommodate a request if you state that the disclosure of all or part of your health information could endanger you.

� Right to Revoke Authorization. You have the right to revoke, in writing, any authorization you have provided to use or disclose your health information, except to the extent that action has already been taken in reliance on your authorization. To revoke an authorization, you must submit your written request to an Entity Privacy Coordinator. Please note that we cannot retract any disclosures we have already made based on your authorization before it was revoked.