Notice Of Privacy Practices Form (Page 2 of 3) in pdf

Authorization, in writing, at any time. If you revoke your Authorization, we will no

longer use or disclose information about you for reasons covered by your written

Authorization, but we cannot take back any uses or disclosures already made with your

permission.

Your Privacy Rights: You have the following rights regarding health information we

obtain about you:

Right to Inspect and Copy: You have the right to inspect and copy your health

information, such as progress notes and billing records. You must submit a written

request to a Brighter & Brighter, PLLC privacy officer in order to inspect and/or copy

your information. If you request a copy of the information, we may charge a fee for the

costs of copying, mailing or other associated supplies. We may deny your request to

inspect/copy in certain limited circumstances. It you are denied access to your

information, you may ask that the denial be reviewed. If such a review is required by law,

we will select a mental health professional to review your request and our denial. The

person conducting the review will not be the person who denied your request, and we will

comply with the outcome of the review.

Right to Amend: If you believe 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 as long as the information is kept by this office.

To request an amendment, complete and submit a Record Amendment/Correction Form

to a Brighter & Brighter, PLLC privacy officer. We may deny your request for an

amendment if it is not in writing or does not include a reason to support the request. In

addition, we may deny your request if you ask us to amend information that:

• We did not create unless the person or entity that created the information is no

longer available to make the amendment

• Is not part of the information we keep

• You would not be permitted to inspect and copy

• Is accurate and complete

Right to an Accounting of Disclosures: You have the right to request an “accounting of

disclosures.” This is a list of the disclosures we made of confidential information about

you. To obtain this list, you must submit your request in writing to a Brighter & Brighter,

PLLC privacy officer. It must state a time period, which may not be longer than six years

and may not include dates before September 2013. Your request should indicate in what

form you want the list, e.g., paper, electronic, etc. We may charge you for the costs of

providing the list. We will notify you of the cost involved and you may choose to

withdraw or modify your request at that time before the costs are incurred.

Right to Request Restrictions: You have the right to request a restriction or limitation

on the confidential information we use or disclose about you. We are not required to

agree to such requests.

Right to Request Confidential Communications: You have the right to request that we

communicate with you about treatment matters in a certain way or at a certain location.

Notice Of Privacy Practices Form Page 2