Common use of Your Protected Health Information Clause in Contracts

Your Protected Health Information. You have the right to request an amendment to your protected health information to correct inaccuracies. To request an amendment, you must send a written request to: Privacy Officer, Health One Alliance, LLC, P.O. Box 1128, Dalton, GA 30722. A form to request an amendment to your protected health information can be obtained from the Privacy Officer. We are not required to grant the request in certain circumstances. Accounting of Disclosures of Your Protected Health Information. You have the right to receive an accounting of certain disclosures of your protected health information made by us within the six years immediately preceding your request. To request an accounting, you must send a written request to: Privacy Officer, Health One Alliance, LLC, P.O. Box 1128, Dalton, GA 30722. A form to request an accounting of your protected health information can be obtained from the Privacy Officer. The first accounting in any 12-month period will be free; however, a fee will be charged to you for any subsequent request for an accounting during that same time.

Your Protected Health Information. You have the right to request an amendment to your Your protected health information to correct inaccuracies. To request an amendment, you You must send a written request to: Privacy Officer, Health One Alliance, LLC, P.O. Box 1128X.X. Xxx 0000, DaltonXxxxxx, GA 30722XX 00000. A form to request an amendment to your Your protected health information can be obtained from the Privacy Officer. We are not required to grant the request in certain circumstances. Accounting of Disclosures of Your Protected Health Information. You have the right to receive an accounting of certain disclosures of your Your protected health information made by us Us within the six years immediately preceding your Your request. To request an accounting, you You must send a written request to: Privacy Officer, Health One Alliance, LLC, P.O. Box 1128X.X. Xxx 0000, DaltonXxxxxx, GA 30722XX 00000. A form to request an accounting of your Your protected health information can be obtained from the Privacy Officer. The first accounting in any 12-month period will be free; however, a fee will be charged to you You for any subsequent request for an accounting during that same time.

Your Protected Health Information. You have the right to request an amendment to your Your protected health information to correct inaccuracies. To request an amendment, you You must send a written request to: Privacy Officer, Health One Alliance, LLC, P.O. Box 1128, Dalton, GA 30722. A form to request an amendment to your Your protected health information can be obtained from the Privacy Officer. We are not required to grant the request in certain circumstances. Accounting of Disclosures of Your Protected Health Information. You have the right to receive an accounting of certain disclosures of your Your protected health information made by us Us within the six years immediately preceding your Your request. To request an accounting, you You must send a written request to: Privacy Officer, Health One Alliance, LLC, P.O. Box 1128, Dalton, GA 30722. A form to request an accounting of your Your protected health information can be obtained from the Privacy Officer. The first accounting in any 12-month period will be free; however, a fee will be charged to you You for any subsequent request for an accounting during that same time.

Your Protected Health Information. You have the right to request an amendment to your protected health information to correct inaccuracies. To request an amendment, you must send a written request to: Privacy Officer, Health One Alliance, LLC,P .X. Xxx 0000, P.O. Box 1128Xxxxxx, Dalton, GA 30722XX 00000. A form to request an amendment to your protected health information can be obtained from the Privacy Officer. We are not required to grant the request in certain circumstances. Accounting of Disclosures of Your Protected Health Information. You have the right to receive an accounting of certain disclosures of your protected health information made by us within the six years immediately preceding your request. To request an accounting, you must send a written request to: Privacy Officer, Health One Alliance, LLC, P.O. Box 1128X.X. Xxx 0000, DaltonXxxxxx, GA 30722XX 00000. A form to request an accounting of your protected health information can be obtained from the Privacy Officer. The first accounting in any 12-month period will be free; however, a fee will be charged to you for any subsequent request for an accounting during that same time.