Notice of Privacy Practices • Page 2
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
• 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.
• 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
• You can ask us to correct health information about you that you think is incorrect
or incomplete. Ask us how to do this.
• We may say “no” to your request, but we’ll tell you why in writing within 60 days.
• 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.
• We will say “yes” to all reasonable requests.
Ask us to limit what
we use or share
• You can ask us not to use or share certain health information for treatment,
payment, or our operations. We are not required to agree to your request, and we
may say “no” if it would affect your care.
• 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. We will say “yes” unless a law requires us to share that information.
Get a list of those
with whom we’ve
• 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.
• 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 12 months.
Get a copy of this
• 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.
to act for you
• 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
• We will make sure the person has this authority and can act for you before we take
File a complaint if
you feel your rights
• You can complain if you feel we have violated your rights by contacting us using the
information on page 1.
• You can ﬁle a complaint with the U.S. Department of Health and Human Services
Ofce for Civil Rights by sending a letter to 200 Independence Avenue, S.W.,
Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/
• We will not retaliate against you for ﬁling a complaint.