Although your health record is the property of Jordan Valley Community Health Center, you have the right to:

• Request restrictions: You have the right to request that JVCHC restrict any use or disclosure of your health information. However, JVCHC is not required to agree to any request unless you are asking JVCHC to restrict the use and disclosure of your Protected Health Information to a health plan for payment or health care operation purposes and such information you wish to restrict pertains solely to a health care item or service for which you have paid JVCHC “out-of- pocket “In full. If restriction is agreed upon, JVCHC will comply with your request unless the information is needed to provide you with emergency treatment. Any request to restrict uses or disclosures must be made in writing to the Privacy Officer at JVCHC. Your request must indicate what information you want limited; whether you want to limit JVCHC’s use, disclosure, or both; and to whom you want the limits to apply.
• Request Confidential Communications: You have the right to request that JVCHC communicate with you about medical matters in a certain way or at a certain location. To request confidential communications, you must make your request, in writing, to the Privacy Officer at JVCHC. Your request must specify how or where you wish to be contacted. We will accommodate reasonable requests.
• Notice of Breach: You have the right to be notified upon a breach of any of your unsecured Protected Health Information.
• An Electronic Copy of Electronic Medical Records: If your Protected Health Information is maintained in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. JVCHC will make every effort to provide access to your Protected Health Information in the form or format you request if it is readily producible in such form or format. If the Protected Health Information is not readily producible in the form or format you request, your record will be provided in either the JVCHC standard electronic format or if you do not want this form or format, a readable hard copy form. JVCHC may charge you a reasonable, cost-based fee for the labor associated with transmitting the electronic medical record.
• Inspect and Copy your Protected Health Information (PHI): You have the right to inspect and copy your protected health information that may be used to make decisions about your care, except for psychotherapy notes. If you want to see or copy your medical information, you must submit your request in writing to Jordan Valley’s privacy Officer. If you request copies, the state-allowed fee will be assessed for the cost associated with your request, including the cost of copies, mailing or other supplies.

ノート： In limited circumstances JVCHC may deny access to your health information. If access is denied, you can request that the denial be reviewed. Another licensed health care professional chosen by JVCHC will review your request and the denial. JVCHC will adhere to the decision of the reviewer.

Request Amendment to your Protected Health Information (PHI): You have the right to request that your health information be amended (changed) if you believe that it is incorrect or incomplete. You have a right to request changes for as long as the information is retained by JVCHC. To request a change in your PHI, you must submit in writing a request to JVCHC’s Privacy Officer which includes the reason you think the information is incorrect or incomplete and specification as to whom you want notified of the change. JVCHC must notify you within 60 days upon receipt of your written request. This period may be extended by 30 days provided we notify you of our reason for the delay and the expected date of completion.

ノート： JVCHC may deny your request if it is not in writing and if it does not include a reason the information should be changed. JVCHC can also deny your request for the following reasons: the information in question was not created by JVCHC or the individual or outside entity is no longer available; the information is not maintained as part of your medical records at JVCHC; the information is not part of the information that you would be permitted to inspect or copy; or JVCHC has reason to believe that the information is accurate and complete.

Accounting of Disclosures: You have the right to receive an accounting of disclosures of medical

information that we have made, with some expectations. You must submit a written request to JVCHC’s Privacy Officer the specific time period of the request and how you want the information reported to you. Re-quests cannot be made for periods longer than six years and may not include dates prior to January 1, 2003. You have the right to receive a free accounting of disclosures every twelve months. If you request more than one accounting in a single twelve-month period, the state-allowed fee will be assessed for the cost associated with your request including the cost of copies, mailing, or other supplies. JVCHC will notify you of the charge for such a request and you will have the opportunity to withdraw or change your request before any cost is incurred. Disclosures made prior to an authorization signed by you or your representatives are exempt from the accounting or disclosures policy.

Receive a Copy of this Notice of Privacy Practices: Even if you have agreed to receive this notice in another form, you can still have a paper copy of this notice. To obtain a paper copy of this notice, contact the medical records department or the Privacy Officer. You can also obtain a copy of this notice at our website: www.jordanvalley.org.