Right to Request Restrictions on Uses and Disclosures

You have the right to request restrictions on the use and disclosure of your PHI. If you request that HFHC not disclose your PHI to a third-party payor health plan for purposes of carrying out payment or health care operations, and you have paid HFHC in full out of pocket for services provided to you, HFHC is required to honor your requested restriction. Otherwise, HFHC is not required to agree to a requested restriction, and it is HFHC’s policy not to agree to such restrictions unless HFHC determines, in HFHC’s sole discretion, that a compelling reason exists to do so.

Right to Request Confidential Communications

You have the right to receive communications from HFHC in a confidential manner and HFHC will accommodate reasonable requests. If you would like HFHC to use an address or telephone number other than your billing address to contact you, you must request so in writing.

Right to Receive an Accounting of Disclosures

You have the right to receive an accounting of certain disclosures of your PHI made by HFHC in the six years prior to the date of your request if you did not specifically authorize those disclosures. The accounting will not include disclosures made directly to you, disclosures made to others pursuant to your written authorization, disclosures made to carry out treatment, payment, and health care operations for which your written authorization was not required, incidental uses and disclosures, and uses and disclosures for which an accounting is not required by law. To receive such an accounting

Right to Access Your Information

You have the right to inspect and copy your PHI in your medical and billing records at reasonable times. If you wish to do so, you will be provided an opportunity to inspect this information within 30 days of receipt of your written request. If HFHC needs extra time, it may extend the time once for an additional 30 days and we will provide you written notice of the extension. You have the right to receive this information in the form and format of your choosing, if such information can be readily produced in such form and format, or in a readable hardcopy form, or in another format agreed to between you and HFHC. If HFHC maintains your PHI in an electronic health record, you have the right to obtain a copy of this information in an electronic format and to direct HFHC to transmit an electronic copy of your PHI directly to another clearly specified entity or person of your choice. In certain limited circumstances, you may be denied access to this information and records. However, you may request that a decision denying you access to this information and records be reviewed. Please contact HFHC’s Privacy Officer if you have questions about your right to access your information. You may be charged reasonable costs for copying your information, or for preparing any summaries that you request.

Right to Request Amendments to Your Information

You have the right to request amendments, corrections and clarifications to PHI contained in your medical and billing records. Your request must be in writing, and you must provide a reason supporting your request. If you wish to do so, please submit the proposed amendment in writing to HFHC at the address given below. If you are requesting a change to the PHI in your treatment record, we will place your request for amendment, correction or clarification in your record. HFHC may add a response to your record and will provide you with a copy of our response. If you are requesting a change in other records (that are neither medical nor billing records), HFHC may deny your request. If your request is denied, we will notify you in writing and provide our reasons for the denial. You have the right to file a statement of disagreement with HFHC and it may prepare a response to your statement. HFHC will provide you with a copy of our response.

Special Rules for Minors

If you are a minor authorized by law to consent to health care services on your own behalf and you in fact consent to such services on your own behalf, HFHC is required to protect the privacy of your PHI with respect to health care services you have consented to on your own behalf in the same way that HFHC protects the privacy of an adult’s PHI, unless a special exception applies under the law. For example, HFHC is authorized by law to notify your parent or guardian if, in the judgment of your HFHC provider failure to inform your parent or guardian would seriously jeopardize your health or would seriously limit the ability of your HFHC provider to provide treatment to you. Additionally, if you want HFHC to bill your parent’s insurance for services provided to you, your parents will receive from their insurance company an Explanation of Benefits regarding the services provided to you by HFHC and, as a result, the fact that you received services from HFHC will not be confidential from your parents. However, if you do not want your parents to know that you are receiving services from HFHC, you must notify HFHC of that fact at the time services are provided to you so that arrangements can be made for payment of such services privately or out-of-pocket, or to determine your eligibility for free or discounted care.

Other Rights:

• You have the right to a paper copy of this Notice of Privacy Practices upon request, even if you agreed to receive this Notice electronically.

• You have the right to request that specific practice staff not have access to your medical records unless it causes undue hardship for HFHC.

• You have the right to complain to HFHC and to the Secretary of the U.S. Department of Health and Human Services if you believe your privacy rights have been violated by HFHC. To file a complaint, please contact HFHC’s Compliance Specialist. HFHC will not retaliate against you for filing a complaint.

For Further information about HFHC’s privacy policies or to submit a complaint, please contact:

Sydney Bebus

Director of Quality and Risk Management

207-483-4778