information we maintain about you. If you request copies, we will charge you areasonable fee to cover the costs of copying, mailing, or other expenses associated with your request. Your request to inspect or review your health information must be submitted in writing to the person listed below. In some circumstances, we may deny your request to inspect and copy your health information. To the extent your information is held in an electronic health record, you may be able to receive the information in an electronic format. Right to Amend. If you believe that information within your records is incorrect or if important information is missing, you have the right to request that we correct the existing information or add the missing information. Your request to amend your health information must be submitted in writing to the person listed below. In some circumstances,we may deny your request to amend your health information.If we deny your request, you may file astatement of disagreement with us for inclusion in any future disclosures of the disputed information. Right to an Accounting of Disclosures. Youhave the right to receive an accounting of certain disclosures of your protected health information. The accounting will not include disclosures that were made (1) for purposes of treatment, payment or health care operations; (2)to you; (3)pursuant to your authorization; (4) to your friends or family in your presence or because of an emergency; (5) for national security purposes; or (6) incidental to otherwise permissible disclosures. Your request for an accounting must be submitted in writing to the person listed below. You may request an accounting of disclosures made within the last six years. Youmay request one accounting free of charge within a 12-month period. Right to Request Restrictions. You have the right to request that we not use or disclose information for treatment, payment, or other administrative purposes except when specifically authorized by you, when required by law, or in emergencycircumstances.Youalso have the right to requestthat we limit the protected health information that we disclose to someone involved in your care or the payment for your care, such as a family member or friend. Your request for restrictions must be submitted in writing to the person listed below. We will consider your request, but in most cases are not legally obligated to agree to those restrictions. However, we will comply with any restriction request if the disclosure is to a health plan for purposes of payment or health care operations (not for treatment) and the protected health information pertains solely to ahealth care item or service that has been paid for out-of-pocketand in full. Right to Request Confidential Communications. Youhave the right to receive confidential communications containing your health information. Your request for restrictions must be submitted in writing to the person listed below. We are required to accommodate reasonable requests. For example, you may ask that we contact you at your place of employment or send communications regarding treatment to an alternate address. Right to be Notified of a Breach. You have the right to be notified in the event that we (or one of our Business Associates) discover abreach of your unsecured protected health information.Notice of any such breach will be made in accordance with federal requirements. Right to Receive aPaperCopy of this Notice. If you have agreed to acceptthis notice electronically, you also have aright to obtain apaper copy of this notice from us upon request. Toobtain apaper copy of this notice, please contact the person listed below.
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