request that the denial be reviewed. Another licensed health care professional chosen by the practice will review
your request and the denial. The person conducting the review will not be the person who denied your request. We
will comply with the outcome of the review.
Amend: If you feel that health 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 as the information is kept
by or for the practice. Any request for an amendment must be sent in writing to the Privacy Officer at this
practice. In addition, you must provide a reason that supports your request.
We may deny your request for an amendment and if this occurs, you will be notified of the reason for the denial. If
we deny your request for amendment, you have the right to file a statement of disagreement with us. We may prepare
a rebuttal to your statement and will provide you with a copy of any such rebuttal. Statements of disagreement and
any corresponding rebuttals will be kept on file and sent out with any future authorized requests for information
pertaining to the appropriate portion of your record.
An Accounting of Disclosures: You have the right to request an accounting (which means a detailed
listing) of disclosures. This is a list of certain disclosures we make of your health information for purposes
other than treatment, payment or health care operations where an authorization was not required. If you request an
accounting more than once every 12 months, we may charge you a fee to cover the costs of preparing the
Request Restrictions: You have the right to request a restriction or limitation on the health
information we use or disclose about you for treatment, payment or health care operations. You also have the right
to request a limit on the health information we disclose about you to someone who is involved in your care or the
payment for your care, like a family member or friend. Example: You could ask that we not use or disclose
information about a surgery you had. Any request for a restriction must be sent in writing to the practice’s
• We are required to agree to your request only if 1) except as otherwise required by law, the disclosure is to
your health plan and the purpose is related to payment or health care operations (and not treatment purposes), and
2) your information pertains solely to health care services for which you have paid in full. For other requests, we
are not required to agree. If we do agree, we will comply with your request unless the information is needed to
provide you emergency treatment.
• You also have the right to request that we restrict disclosures of your medical information and healthcare
treatment(s) to a health pan (health insurer) or other party, when that information relates solely to a healthcare
item or service for which you, or another person on your behalf (other than a health plan), has paid us for in
full. Once you have requested such restriction(s), and your payment has in full has been received, we must follow
Request Confidential Communications: You have the right to request that we communicate with you
about medical matters in a certain way or at a certain location. Example: You may ask that we contact you at work
instead of your home. The practice will grant reasonable requests for confidential communications at alternative
locations and/or via alternative means only if the request is submitted in writing to the practice’s Privacy
Officer and the written request includes a mailing address where the individual will receive bills for services
rendered by the practice and related correspondence regarding payment for services. Please realize, we reserve the
right to contact you by other means and at other locations if you fail to respond to any communication from us that
requires a response. We will notify you in accordance with your original request prior to attempting to contact you
by other means or at another location. We reserve the right to deny a request if it imposes an unreasonable burden
on the practice.
Right to Opt-Out of Fundraising Communications: If we conduct fundraising and we use
communications like the U.S. Postal Service or electronic mail for fundraising, you have the right to opt-out of
receiving such communications from us.