Hipaa Privacy Policy Notice Page 3

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3. Subject to payment of a reasonable copying charge as provided by state law, you have the right to inspect or obtain a copy of the
protected health information contained in your medical and billing records and in any other practice records used by us to make
decisions about you, except for:
♦ Psychotherapy notes, which are notes recorded by a mental health professional documenting or analyzing the contents of
conversation during a private counseling session or a group, joint or family counseling session and that have been
separated from the rest of your medical record
♦ Information compiled in a reasonable anticipation of, or for use in, a civil, criminal, or administrative action or
proceeding.
♦ Protected health information involving laboratory tests when your access is required by law
♦ If you are a prison inmate and obtaining such information would jeopardize your health, safety, security, custody, or
rehabilitation or that of other inmates, or the safety of any officer, employee, or other person at the correctional
institution or person responsible for transporting you
♦ If we obtained or created protected health information as part of a research study for as long as the research is in
progress, provided that you agreed to the temporary denial of access when consenting to participate in the research
♦ Your protected health information is contained in records kept by a federal agency or contractor when your access is
required by law
♦ If the protected health information was obtained from someone other than us under a promise of confidentiality and the
access requested would be reasonably likely to reveal the source of the information
We may also deny a request for access to protected health information if:
♦ A licensed health care professional has determined, in the exercise of professional judgment, that the access requested is
reasonably likely to endanger your life or physical safety or that of another person
♦ The protected health information makes reference to another person (unless such other person is a health care provider)
and a licensed health care professional has determined, in the exercise of professional judgment, that the access
requested is reasonably likely to cause substantial harm to such other person
♦ The request for access is made by the individual’s personal representative and a licensed health care professional has
determined, in the exercise of professional judgment, that the provision of access to such personal representative is
reasonably likely to cause substantial harm to you or another person
If we deny a request for access for any of the three reasons described above, then you have the right to have our denial
reviewed in accordance with the requirements of applicable law.
4. You have the right to request a correction to your protected health information, but we may deny your request for correction, if
we determine that the protected health information or record that is the subject of the request:
♦ Was not created by us, unless you provide a reasonable basis to believe that the originator of protected health information is
no longer available to act on the requested amendment
♦ Is not part of your medical or billing records
♦ Is not available for inspection as set forth above
♦ Is not accurate and complete
In any event, any agreed upon correction will be included as an addition to, and not a replacement of, already existing records.
5. You have the right to receive an accounting of disclosures of protected health information made by us to individuals or entities
other than to you for the period provided by law, except for disclosures:
♦ To carry out treatment, payment and health care operations as provided above
♦ To persons involved in your care or for other notification purposes as provided by law
♦ For national security or intelligence purposes as provided by law
♦ To correctional institutions or law enforcement officials as provided by law
♦ That occurred prior to April 14, 2003
♦ That are otherwise not required by law to be included in the accounting
6. You have the right to request and receive a paper copy of this notice from us.
7. The above rights may be exercised only by written communication to us. Any revocation or other modification of consent must
be in writing delivered to us.

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