Notice of Privacy Practices - page 4

Get a list
of those
with whom
we’ve shared
You can ask for a list (accounting) of the times we’ve
shared your health information for six years prior to
the date you ask, who we shared it with, and why.
We will include all the disclosures except for
those about treatment, payment, and health care
operations, and certain other disclosures (such as any
you asked us to make). We’ll provide one accounting a
year for free but will charge a reasonable, cost-based
fee if you ask for another one within 12 months.
Get a copy of
this privacy
You can ask for a paper copy of this notice at any
time, even if you have agreed to receive the notice
electronically. We will provide you with a paper copy
Choose someone
to act for you
If you have given someone medical power of attorney
or if someone is your legal guardian, that person can
exercise your rights and make choices about your
health information.
We will make sure the person has this authority and
can act for you before we take any action.
File a complaint
if you feel your
rights are violated
You can complain if you feel we have violated your
rights by contacting us using the information on the
back page.
You can file a complaint with the U.S. Department
of Health and Human Services Office for Civil Rights
by sending a letter to 200 Independence Avenue,
S.W., Washington, D.C. 20201, calling 1-877-696-
6775, or visiting
We will not retaliate against you for filing a complaint.
Notice of Privacy Practices • Page 3
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