"Privacy Notice Page #2"
PO Box 159, 1033 Highway 45 South
Cofield, NC 27922-0159
(252) 356-1165 or (252) 356-1121
Fax: (252) 356-2374
Other than what is stated on the previous page, the Agency will not disclose your health information other than with your written authorization. If you or your representative authorizies the Agency to use or disclose your health information, you may revoke that authorization in writing at any time.
YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION:
You have the following rights regarding your health information that the Agency maintains:
Right to request restrictions: You may request restrictions on uses and disclosures of your health information. You have the right to request a limit on the disclosure of your health information to someone who is involved in your care or the payment of your care. However, the Agency is not required to agree to your request. (Form H540)..
Rights to receive confidential comunications: You have the right to request that the Agency communicate with you in a certain way. For example, you way ask that the Agency conduct communications pertaining to your health information privately with no other family members present. If you wish to receive confidential communications, please contact the Agency Administrator. The Agency will not request that you provide any reasons for your request and will attempt to honor your reasonable requests for confidential communications (Form H516).
Rights to Inspect and copy your health information: You and your representative have the right to inspect and copy your health information, including billing records. A request to inspect and copy records containing your health informaton may be made to the Agency Administrator. If you request a copy of health information, the Agency will charge a reasonable fee for copying and assembling cost associated with your request.
Right to amend health care information: You or your representative have the right to request that the Agency amend your records, if you believe the information is incorrect or incomplete. That request may be made as long as the information is maintained by the Agency. A request for an amendment of records must be made in writing.
The Agency may deny the request if it is not in writing or does not include a reason for the amendment. The request aslo my be denied if your health information records were not created by the Agency. If the records you are requesting are not part of the Agency's records, if the information you wish to amend is not part of your information you or your representative are permitted to inspect and copy, or if the opinion of the Agency, the records containing health information are accurate and complete.
Hattie A. Powell, President
PO Box 159, 1033 Highway 45 South
Cofield, NC 27922-0159
