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Your Rights When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you. Get an electronic or paper copy of your medical record U You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. U We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee. Ask us to correct your medical record U You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. U We may say “no” to your request, but we’ll tell you why in writing within 60 days. Request confidential communications U You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. U We will say “yes” to all reasonable requests. continued on next page ÌVi v *ÀÛ>VÞ *À>VÌVià U *>}i £ Your Rights continued Ask us to limit what we use or share U You can ask us not to use or share certain health information for treatment, payment, or our operations. U We are not required to agree to your request, and we may say “no” if it would affect your care. U If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. U We will say “yes” unless a law requires us to share that information. Get a list of those with whom we’ve shared information U You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. U We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within £Ó Ì Ã° Get a copy of this privacy notice U You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly. Choose someone to act for you U If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. U We will make sure the person has this authority and can act for you before we take any action. File a complaint if you feel your rights are violated U You can complain if you feel we have violated your rights by contacting us ÕÃ} Ì i vÀ>Ì «>}i £° U You can file a complaint with the U.S. Department of Health and Human -iÀÛVià "vwVi vÀ CÛ ,} Ìà LÞ Ãi`} > iÌÌiÀ Ì Óää I`i«i`iVi AÛiÕi] -°7°] 7>à }Ì] D°C° ÓäÓä£] V>} £nÇÇÈÈÈÇÇx] À visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. U We will not retaliate against you for filing a complaint. ÌVi v *ÀÛ>VÞ *À>VÌVià U *>}i Ó Your Choices For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to: U Share information with your family, close friends, or others involved in your care U Share information in a disaster relief situation U Include your information in a hospital directory U Contact you for fundraising efforts If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety. In these cases we never share your information unless you give us written permission: U Marketing purposes U Sale of your information U Most sharing of psychotherapy notes In the case of fundraising: U We may contact you for fundraising efforts, but you can tell us not to contact you again. Our Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following ways. Treat you U We can use your health information and share it with other professionals who are treating you.
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