Psychiatric Intake Form Page 8
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Choose someone to act for you
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File a complaint if you believe your privacy rights have been violated
You have choices in the way that we use and share information as we:
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Tell family and friends about your condition
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Provide disaster relief
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Include you in a hospital directory
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Provide mental health care
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Market our services and sell your information
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Raise funds
We may use and share your information as we:
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Treat you
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Run our organization
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Bill for your services
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Help with public health and safety issues
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Do research
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Comply with the law
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Respond to organ and tissue donation requests
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Work with a medical examiner or funeral director
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Address workers’ compensation, law enforcement, and other government requests
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Respond to lawsuits and legal actions
Your Rights
When it comes to your health information, you have certain rights. This section explains your rights and some of our
responsibilities to help you.
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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 in- formation we have about you. Ask us how to do this. We will provide a
copy or a summary of your health information, usually within 30 days of your request. We may charge a
reasonable, cost-based fee.
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Ask us to correct your medical record: You can ask us to correct health information about you that you think is
incorrect or incomplete. Ask us how to do this. We may say “no” to your request, but we’ll tell you why in writing
within 60 days.
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Request confidential communications: 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.
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Ask us to limit what we use or share: You can ask us not to use or share certain health information for treatment,
payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect
your care. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that
information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law
requires us to share that information.
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Get a list of those with whom we’ve shared information: You can ask for a list (accounting) of the times we’ve
shared your health information for six years prior to the date you ask, who we shared it with, and why. We will
include all the disclosures except for those about treatment, payment, and health care operations, and certain
other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge
a reasonable, cost-based fee if you ask for another one within 12 months.
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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. We will provide you with a paper copy promptly.
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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. We will make sure
the person has this authority and can act for you before we take any action.
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File a complaint if you feel your rights are violated: You can complain if you feel we have violated your rights by
contacting us using the information on page 1. You can file a complaint with the U.S. Department of Health and
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