Page 24 - Home Health Marketing

If we deny access to protected health information, you will receive a timely, written denial in plain language
that explains the basis for the denial, your review rights and an explanation of how to exercise those rights. If
we do not maintain the medical record, we will tell you where to request the protected health information.
 Request to amend protected health information for as long as the protected health information is maintained
in the designated record set. A request to amend your record must be in writing and must include a reason to
support the requested amendment. We will act on your request within sixty (60) days of receipt of the request.
We may extend the time for such action by up to 30 days, if we provide you with a written explanation of the
reasons for the delay and the date by which we will complete action on the request.
We may deny the request for amendment if the information contained in the record was not created by us, unless
you provide a reasonable basis for believing the originator of the information is no longer available to act on the
requested amendment; is not part of the designated medical record set; would not be available for inspection under
applicable laws and regulations; or the record is accurate and complete. If we deny your request for amendment,
you will receive a timely, written denial in plain language that explains the basis for the denial, your rights to submit
a statement disagreeing with the denial and an explanation of how to submit that statement.
 Receive an accounting of disclosures of protected health information made by our Agency for up to six
(6) years prior to the date on which the accounting is requested for any reason other than for treatment,
payment or health operations and other applicable exceptions. The written accounting includes the date of
each disclosure, the name/address (if known) of the entity or person who received the protected health
information, a brief description of the information disclosed and a brief statement of the purpose of the
disclosure or a copy of the written request for disclosure. We will provide the accountings within 60 days of
receipt of a written request. However, we may extend the time period for providing the accounting by 30 days
if we provide you with a written statement of the reasons for the delay and the date by which you will receive
the information. We will provide the first accounting you request during any 12-month period without charge.
Subsequent accounting requests may be subject to a reasonable cost-based fee.
 Receive notification of any breach in the acquisition, access, use or disclosure of unsecured protected
health information by the agency, its business associates and/or subcontractors.
 Obtain a paper copy of this notice, even if you had agreed to receive this notice electronically, from us
upon request.
COMPLAINTS – If you believe that your privacy rights have been violated, you may complain to the Agency or to
the Secretary of the U.S. Department of Health and Human Services. There will be no retaliation against you for
filing a complaint. The complaint should be filed in writing, and should state the specific incident(s) in terms of
subject, date and other relevant matters. A complaint to the Secretary must be filed in writing within 180 days of
when the act or omission complained of occurred, and must describe the acts or omissions believed to be in
violation of applicable requirements. For further information regarding filing a complaint or further information
about matters covered by this notice, contact: PLEASE SPECIFY
Name or title of Contact Person or Office _________________________________
Agency Name ______________________________________
Address _______________________________________
Phone ___________________________
EFFECTIVE DATE – This notice is effective (date): ___________. We are required to abide by the terms of
the notice currently in effect, but we reserve the right to change these terms as necessary for all protected health
information that we maintain. If we change the terms of this notice (while you are receiving service), we will
promptly revise and distribute a revised notice to you as soon as practicable by mail, email (if you have agreed to
THE EFFECTIVE DATE WILL BE
electronic notice), hand delivery or by posting on our website. THE DATE YOUR BOOK IS
FINALIZED AND GOES TO PRINT

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