You have the right to inspect and copy your protected health information You can ask to see or get a paper or electronic copy of your health information. We will provide a copy, or a summary of your health information, usually within 15 days of your request. We may charge a reasonable, cost-based fee as permissible by law.
Exceptions to record release: Psychotherapy process notes; information deemed harmful, unless required by law; information compiled in reasonable anticipation of, or use in, civil, criminal, or administrative action or proceeding or that are subject to law that prohibits access to protected health information.
You have the right to request a restriction of your protected health information You may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment, or mental health care operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care. We will say “yes” unless required by law to share information.
You have the right to request to receive confidential communications from us by alternative means. 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.
You have the right to request an amendment of your protected health information You can ask us to correct health information about you that you think is incorrect or incomplete. In certain cases we may deny your request for an amendment and will provide a written explanation to you within 60 days of your request.
You have the right to request an accounting of certain disclosures we have made, if any, of your protected health information You can ask for a list (accounting) of the times we have shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all disclosures except those about treatment, payment, and health care operations, and certain other disclosures (such as those you asked us to make). We will provide one accounting a year for free, but will charge a reasonable, cost-based fee for additional requests within a 12-month period.
You can choose someone 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 information.
You have a right to obtain a paper copy of this form from us.
You have the right to file a complaint if you feel your rights are being violated. You can contact us directly to discuss concerns you have about how your health information and your rights associated with such information. If we are unable to resolve your concerns, you have the right to file a complaint with the U.S. Department of Health and Human Services Office of Civil Rights. We will not retaliate against you for filing a complaint.