CLIENT RIGHTS

Right to request how we contact you
It is our normal practice to communicate with you at your home address and daytime phone number you gave us when you scheduled your appointment, about health matters, such as appointment reminders etc.  Sometimes we may leave messages on your voicemail.  You have the right to request that our office communicate with you in a different way.  May we contact you at home (circle one)  yes no?    May we contact you at work  yes no?.  May we contact you by cell phone  yes no?   Where may we contact  you________________________________________?

Right to release your medical records
You may consent in writing to release your records to others.  You have the right to revoke this authorization, in writing, at any time. However, a revocation is not valid to the extent that we  acted in reliance on such authorization

Right to inspect and copy your medical and billing records.
You have the right to inspect and obtain a copy of your information contained in our medical records.  To request access to your billing or health information, contact the office manager.  Under limited circumstance we may deny your request to inspect and copy. If you ask for a copy of any information, we may charge a reasonable fee for the costs of copying, mailing and supplies.

Right to add information or amend your medical records.
If you feel that information contained in your medical record is incorrect or incomplete, you may ask us to add information to amend the record.  We will make a decision on your request with 60 days, or some cases within 90 days.  Under certain circumstance, we may deny your request to add or amend information.  If we deny your request, you have a right to file a statement that you disagree. Your statement and our response will be added to your record. To request an amendment, you must contact the office manager.  We will require you to submit your request in writing and to provide an explanation concerning the reason for your request.

Right to an accounting of disclosures.
You may request an accounting of any disclosures, if any, we have made related to your medical information, except for information we used for treatment, payment, or health care operational purposes or that we shared with you or your family, or information that you gave us specific consent to release.  It also excludes information we were required to release. To receive information regarding disclosure made for a specific time period no longer than six years and after April 14, 2003, please submit your request in writing to the Privacy Officer.  We will notify you of the cost involved in preparing this list.

Right to request restrictions on uses and disclosures of your health information.
You have the right to ask for restrictions on certain uses and disclosures of your health information. This request must be in writing and submitted to our office manager. However, we are not required to agree to such a request. 

Right to complain.
If you believe your privacy rights have been violated, please contact us personally, and discuss your concerns.  If you are not satisfied with the outcome, you may file a written complaint with the U.S. Department of Health and Human Services. An individual will not be retaliated against for filing such a complaint. 

Right to receive changes in policy. 
You have the right to receive any future policy changes secondary to changes in state and federal laws. This can be obtained from the office manager.