Right to a Paper Copy of This Notice. You have a right to obtain a paper copy of this notice. You may obtain a copy by notifying Transformations office at 502/899-5411 or mailing a request to 0000 Xxxxxx Xxxxxx, Xxxxx 000, Xxxxxxxxxx, XX 00000. Right to amend your/your child's health information You have the right to request the agency to amend the health information we maintain about you/your child if you feel it is incorrect or incomplete for as long as the information is kept by Transformations. To request an amendment, you must submit a request in writing and state the reason that supports your request. The disputed information will remain in the record along with the amended information. Transformation may deny your request if the request is not submitted in writing, does not contain a reason to support the request, the information that is being questioned was not originated by Transformations, it is not part of the information which you are permitted to inspect or copy, or it is currently accurate and complete. Right to an accounting of disclosures You have the right to obtain an accounting of the disclosures Transformations made of health information about you/your child. This does not include disclosures made for treatment, payment, or health care operations, made directly to you, made for national security reasons, or made to corrections or law enforcement personnel. Your request must state a time period that must be no longer than (6) six years and may not include dates before April 14, 2003. The first list requested within a (12) twelve month period will be free. For additional lists, you will be charged for the cost of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request before any costs are incurred. Right to request alternative means of communication Transformations’ staff may seek to communicate with you through general common practices such as your cell phone, text messages, email, voice mail, the U.S. Postal service, etc. It is our policy to take reasonable measures to secure electronic communications. You have the right to request communication of your/your child's health information by alternative means or alternative locations. For example, you could request Transformations only contact you at work or by mail. To request communications by alternative or restricted means, you must submit your request in writing. You will not be asked the reason for your request and your request will be accommodated. Your request mu...
Right to a Paper Copy of This Notice. You are entitled to receive a paper copy of our notice of privacy practices. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact Xxxxx Xxxxxxx, M.D.
Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice at our website, xxx.xxxxxxxxx.xxx. To obtain a paper copy of this notice, please submit a written request by facsimile to Soberlink Healthcare LLC @ 000-000-0000 Attn: Privacy Officer, by mail to Soberlink Healthcare LLC, Attn: Privacy Officer, 00000 Xxxxx Xxxxxxxxx, #000, Xxxxxxxxxx Xxxxx, XX 00000 or by email to xxxxxxx@xxxxxxxxx.xxx.
Right to a Paper Copy of This Notice. You may ask us for a paper copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are entitled to receive a paper copy of this Notice. To obtain a paper copy of this Notice, ask any staff person. You may also obtain a copy of this Notice at our website xxx.xxxxxx.xxx.
Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.
Right to a Paper Copy of This Notice. You may ask us for a paper copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are entitled to receive a paper copy of this Notice. To obtain a paper copy of this Notice, ask any staff person. You may also obtain a copy of this Notice at our website xxx.xxxxxx.xxx. San Diego County CoC Homeless Management Information System (HMIS) Notice of Privacy Practices COMPLAINTS You have the right to file a complaint if you believe that RTFH staff has not complied with the practices outlined in this Notice. All complaints must be submitted in writing. You will not be penalized in any way for filing a complaint. If you believe your privacy rights have been violated, you may file a complaint with the RTFH. To file a complaint with the RTFH, contact: Regional Task Force on the Homeless 0000 Xxxxxx Xxxxxx Rd., San Diego, CA 92123 858-292-7627 To file a complaint with the State of California, contact: xxx.xxxxxxx.xx.xxx 000-000-0000 000-000-0000 ACKNOWLEDGEMENT OF RECEIPT By signing this form, you acknowledge receipt of the HMIS Notice of Privacy Practices. Our Notice of Privacy Practices provides information about how we may use and disclose your protected information. We encourage you to read it in full. Our Notice of Privacy Practices is subject to change. If we change our notice, you may obtain a copy of the revised notice by accessing our web site, xxxx://xxx.xxxxxx.xxx/ or by contacting any staff person involved in your services. If you have any questions about our Notice of Privacy Practices, please contact: Regional Task Force on the Homeless 0000 Xxxxxx Xxxxxx Rd., San Diego, CA 92123 858-292-7627 I acknowledge receipt of the HMIS Notice of Privacy Practices. Client Signature Client Name, Printed Date Inability to Obtain Acknowledgement To be completed only if no signature is obtained. If it is not possible to obtain the client’s acknowledgement, describe the good faith efforts made to obtain the client’s acknowledgement, and the reasons why the acknowledgement was not obtained: Staff Member’s Signature Staff Name and Title Printed Date San Diego County CoC Homeless Management Information System (HMIS) Summary of Privacy Practices THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED SHARED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY Effective Date: Our Duty to Safeguard Your Protected Information [ENTER AGENCY NAME HERE] collects information about who uses our services. We will a...
Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice at our web site, To obtain a paper copy of this notice, you must make your request, in writing, to Empower Family Medicine LLC, 000X Xxxxxxx Xxx, Xxxxx 000, Xxxxxxx XX 00000 CHANGES TO THIS NOTICE: We reserve the right to change this notice and make the new notice apply to Health Information we already have as well as any information we receive in the future. We will post a copy of our current notice at our office. The notice will contain the effective date on the first page, in the top right‐hand corner.
Right to a Paper Copy of This Notice. You have the right to request a paper copy of this Notice at any time, even if you have agreed to receive this Notice electronically. Requests for paper copies may be obtained when registering at a Lifespan affiliate or can be requested, in writing, from either the Lifespan Privacy Officer, or the appropriate Lifespan Affiliate Privacy Officer listed at the end of this Notice.
Right to a Paper Copy of This Notice. You have a right to a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice. You can obtain an additional copy by asking for one at the time of your next visit or by accessing our website at xxx.xxxxxxx.xxx, or by writing USFPG Clinical Operations Health Information Management at the address listed at the end of this Notice.
Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice at any time. CHANGES TO THIS NOTICE We reserve the right to change or revise this agreement without notice.
