Instructions For Form Des-1077a - Notice Of Privacy Practices (Page 2 of 2) in pdf

Your Other Rights Concerning Your Health Information Includes the Right to:

• See and get copies of your records. You may be charged a fee for the cost of copying your records.

• Request to have your records amended or corrected if you think there is a mistake. You must provide a reason for your request.

• Receive a list of disclosures. This list will not include the time that information was disclosed for treatment, payment or health

care operations. The list will not include information provided to you or your family directly, or information that was sent with

your authorization.

• Further restrict uses and disclosures of your health information. You must tell DES what information you want to limit and to

whom you want the limits to apply. DES is not required to agree to the restriction.

• Cancel authorizations previously provided by you to DES. This cancellation, however, will not affect any information that has

already been shared.

• Receive a written notification in the event of a breach of your protected information.

• Choose how the program communicates with you in a certain way or at a certain place.

• Opt out of receiving fundraising communications.

• File a complaint if you do not agree with how DES has used or disclosed information about you.

• Receive a paper copy of this notice at any time.

ANY REQUEST YOU MAKE TO DES MUST BE IN WRITING

How to Contact DES Regarding Your Privacy Rights:

Mail all written forms, requests and correspondence to:

Arizona Department of Economic Security

Chief Privacy Officer

Mail Drop 1292

1789 W. Jefferson

Phoenix, AZ 85007

The Privacy Officer may deny your request to look at, copy or change your records. If DES denies your requests, DES will send you a

letter that tells you why your request is being denied and if you can request a review of that denial.

How to File a Complaint:

You may file a complaint with DES or the U.S. Department of Health and Human Services-Office of Civil Rights:

(You will not be retaliated against for filing a complaint)

Send correspondence to:

Arizona Department of Economic Security

-OR-

Department of Health and Human Services

Chief Privacy Officer

200 Independence Avenue, SW

1789 W. Jefferson Street

HHH Building, Room 509H

Mail Drop 1292

Washington, D.C. 20201

Phoenix, AZ 85007

For More Information:

If you have any questions about this notice or need more information, please contact the DES Privacy Officer. DES may change its

Notice of Privacy Practices. Any changes will apply to information DES already has, as well as any information DES may get in the

future. A copy of any new notice will be posted at the DES HIPAA Administration Office as well as its web site. You may ask for a

copy of the current notice at any time, or get it on-line at

Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans

with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II

of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in admissions, programs,

services, activities, or employment based on race, color, religion, sex, national origin, age, disability, genetics and retaliation. The

Department must make a reasonable accommodation to allow a person with a disability to take part in a program, service or activity.

For example, this means if necessary, the Department must provide sign language interpreters for people who are deaf, a wheelchair

accessible location, or enlarged print materials. It also means that the Department will take any other reasonable action that allows you

to take part in and understand a program or activity, including making reasonable changes to an activity. If you believe that you will

not be able to understand or take part in a program or activity because of your disability, please let us know of your disability needs in

advance if at all possible. To request this document in alternative format or for further information about this policy, contact the Chief

Privacy Officer; TTY/TDD Services: 7-1-1. • Free language assistance for DES services is available upon request. • Disponible en

español en línea o en la oficina local.

Instructions For Form Des-1077a - Notice Of Privacy Practices Page 2

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