I. You have the right to request restrictions on uses and disclosures of PHI about you. You have the right to request that I restrict the use and disclosure of PHI about you. I am not required to agree to your requested restrictions. If I agree to your request, in certain situations your restrictions may not be followed. These situations include (but are not limited to):

• Emergency treatment and disclosures to the Secretary of the Department of Health and Human Services. You may request a restriction by writing me.

II. You have the right to specify how I communicate with you.
You have the right to request how and where I contact you about PHI.

You may request that I contact you at work, by phone or by email.

Your request must be in writing and I must accommodate reasonable requests.

When appropriate this accommodation may be breached if you have not provided accurate information regarding how payment, if any, will be handled.

You may request alternative communications by writing to me.

III. You have the right to see and copy PHI about you. You have the right to see and receive a copy of PHI contained in clinical, billing and other records used to make decisions about you. Your request must be in writing, and there may be an additional related fee.

Instead of providing you with a full copy of the PHI, I may give you a summary or explanation of the PHI about you, if you agree in advance to the form and cost of the summary or explanation.

There are certain situations in which I am not required to comply with your request. Under these circumstances, I will respond to you in writing, stating why I will not grant your request and describing any rights you may have to request a review of my denial.

You may request to see and receive a copy of PHI by writing to me.

IV. You have the right to request amendment of Protected Health Information about you.

You have the right to request that I make amendments to clinical, billing and other records used to make decisions about you. Your request must be in writing and must explain your reason(s) for the amendment.

I may deny your request if:

1. the information was not created by me (unless you prove the creator of the information is no longer available to amend the record);
2. the information is not part of the records used to make decisions about you;
3. I believe the information is correct and complete; or
4. you would not have the right to see and copy the record as described in number three.

I will inform you in writing the reasons for the denial and describe your rights to give me a written statement disagreeing with the denial. If I accept your request to amend the information, I will make reasonable efforts to inform others of the amendment, including persons you name who have received PHI about you and who need the amendment.

You may request an amendment of your PHI by writing to me. If you ask me in writing, you have the right to receive a written list of certain of my disclosures of PHI about you.

You may ask for disclosures made up to six (6) years before your request (not including disclosures made prior to April 14, 2003 ).

I am required to provide a listing of all disclosures except the following:

• For your treatment
• For billing and collection of payment for your treatment
• For my health care operations
• Made to or requested by you, or someone that you authorized
• Occurring as a byproduct of permitted uses and disclosures
• Made to individuals involved in your care, for directory or notification purposes, or for other purposes described above
• Allowed by law when the use and/or disclosure related to certain specialized government functions or related to correctional institutions and in other law enforcement custodial situations and
• As a part of a limited set of information which does not contain certain information which would identify you. This list will include the date of the disclosure, the name (and address, if available) of the person or organization receiving the information, a brief description of the information disclosed, and the purpose of the disclosure.

If, under permitted circumstances, PHI about you has been disclosed for certain types of research projects, the list may include different types of information.

If you request a list of disclosures more than once in 12 months, I can charge you a reasonable fee. You may request a listing of disclosures by writing to me.

V. You have a right to copy this notice.

You have the right to request a paper copy of this Notice at any time by calling or visiting my office during normal business hours.

I will provide a copy of this Notice no later than the date you first receive service from me, after April 14, 2003 (except for emergency services, and then I will provide the Notice to you as soon as possible).

Please sign, date and bring this notice to your first appointment.

___________________________________

(Client)

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(Date)