You have the right to:
- Get a copy of your paper or electronic medical record
- Correct your paper or electronic medical record
- Request confidential communication
- Ask me to limit the information I share with other professionals
- Get a list of those with whom I’ve shared your information
- Get a copy of this privacy notice
- Choose someone to act for you
- File a complaint if you believe your privacy rights have been violated
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
- You can ask to see or get an electronic or paper copy of your medical record and other health information I have about you. Ask me how to do this.
- I will provide a copy or a summary of your health information. I may charge a reasonable, cost-based fee.
Request confidential communications
- You can ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
Ask me to limit what I use or share with other professionals
- You can ask me not to use or share certain health information for treatment, payment, or our operations. I am not required to agree to your request, but I want you to ask.
- If you pay for a service or health care item out-of-pocket in full, you can ask me not to share that information for the purpose of payment or my operations with your health insurer. I will agree unless a law requires me to share that information.
Get a list of those with whom we’ve shared information
- You can ask for a list of the times I’ve shared your health information for six years prior to the date you ask, who I shared it with, and why.
- I will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked me to make).
Get a copy of this privacy notice
- You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically.
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.
- I will make sure the person has this authority and can act for you before I take any action.
File a complaint if you feel your rights are violated
- You can complain if you feel I have violated your rights by contacting me using the CONTACT page.
- You can file a complaint with my clinical supervisor, at any time, by emailing him at firstname.lastname@example.org.
- I will not retaliate against you for filing a complaint.
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