Hipaa Notice Of Privacy Practices Form - Nebraska (Page 2 of 2) in pdf

Your Rights:

Following is a statement of your rights with respect to your Protected Health Information (PHI).

You have the right to inspect and copy your PHI. Under the federal law, however, you may not inspect or copy the

following records: psychotherapy notes, information compiled in reasonable anticipation of, or use in, a civil, criminal,

or administrative action or proceeding, and PHI that is subject to law that prohibits access to PHI.

You have the right to request a restriction of your PHI. This means you may ask us not to use or disclose any

part of your PHI for the purposes of treatment, payment or healthcare operations. You may also request that any

part of your PHI not be disclosed to family members or friends who may be involved in your care or for notification

purposes as described in the Notice of Privacy Practices. Your request must state the specific restriction requested

and to whom you want the restriction to apply.

Your physician is not required to agree to a restriction that you may request. If physician believes it is in your best

interest to permit use and disclosure of your PHI, your PHI will not be restricted. You then have the right to use

another Healthcare Professional.

You have the right to request to receive confidential communications from us by alternative means or at an

alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if

you have agreed to accept this notice alternatively i.e. electronically.

You may have the right to have your physician amend your PHI.

If we deny your request for amendment, you

have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and

provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if any, of your PHI.

We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have

the right to object or withdraw as provided in this notice.

Complaints.

You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have

been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will

not retaliate against you for filing a complaint.

This notice was published and becomes effective on/or before April 14, 2003.

We are required by law to maintain the privacy of, and provide individuals with, this notice or our legal duties and

privacy practices with respect to PHI. If you have any objections to this form, please ask to speak with our HIPAA

Compliance Officer in person or by phone at our Main Phone Number.

Signature below is only acknowledgement that you have received this Notice of our Privacy Practices:

Name:_____________________________Signature:____________________________ Print Date:_____________

Hipaa Notice Of Privacy Practices Form - Nebraska Page 2