Text Box: YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU You have the following rights regarding medical information we maintain about you. Right to Inspect and Copy: You have the right to inspect and request copies of medical information that may be used to make decisions about your care. Usually, this information includes medical and billing records, but does not include psychotherapy notes. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to the Manager of Medical Records. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with the request. We may deny your request to inspect and copy in certain limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Right to Amend: If you feel that the 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 the information is kept by or for the organization. To request an amendment, your request must be made in writing and submitted to the Manager of Medical Records. 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. Is not part of the medical information kept by us. Is not part of the information which would be permitted to inspect and copy. Is accurate and complete; or For other reasons provided by State Law. If we deny your request for amendment, we will notify you and provide reasons for denial. Right to an Accounting of Disclosures: You have the right to request a list of disclosures (also called an accounting of disclosures) we made of medical information about you. To request this list or accounting of disclosures, you must submit your request in writing to the Manager of Medical Records. Your request must state the time period which may not be longer than 6 years and may not include dates before April 14, 2003. Your request should indicate what form you want the list (i.e.: paper, electronically). The first list you request within a 12 month period will be free of charge. For additional lists a cost may be applied. Right to Request Restrictions: You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or healthcare services. You also have the right to request a limit on the medical Text Box: We may release personal heath information to a coroner or medical examiner. We may release your personal health information to workers’ compensation and similar programs. Information about you also will be disclosed when necessary to prevent a serious threat to your health and safety or the health and safety of others. Appointment reminders: We may use and disclose medical information in order to contact you to remind you of an appointment or that you should schedule an appointment. Treatment Alternatives: We may use and disclose your personal health information in order to tell you about or recommend possible treatment options or alternatives that may be of interest to you. Health-Related Benefits and Services: We may use and disclose medical information in order to tell you about health–related benefits or services that may be of interest to you. Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information request. De-Identified Information: Please be aware that we may also provide other businesses certain “de-identified” information that may group you with other similarly situated or treated individuals. This de-identified information may be used for educational purposes, research purposes, market analysis, or marketing purposes. Military and Veterans: If you are a member of the Armed Forces, we may release personal health information about you as required by military command authorities. We also may release health information about foreign military personnel to the appropriate military authority. To the extent another state or federal law restricts the ability of the practice to use or disclose protected health information as discussed above, the practice description of the use or disclosure must reflect the more stringent law. OTHER USES AND DISCLOSURE OF PERSONAL INFORMATION We are required to obtain written authorization from you for any other uses and disclosures of medical information other than those described above. If you provide us with such permission, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose personal information about you for the reasons covered by the written authorization. We will be unable to reclaim any disclosures already made based upon the original permission.

Privacy Practices (page 2)

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