If you believe that your PHI in our records is incorrect or incomplete, you may ask us to amend the information. You must submit your request for amendment in writing. You must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend PHI that:
If we deny your request for amendment, you have the right to submit a written request for reviewing the denial access, with respect to any item or statement in your record you believe is incomplete or incorrect. If you clearly indicate in writing that you want your denial request to be made part of your medical record we will attach it to your records and include it whenever we make a disclosure of the item or statement you believe to be incomplete or incorrect.
Right to an Accounting of Disclosures
You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of your PHI other than our own uses for treatment, payment, and health care operations (as those functions are described above) or pursuant to your authorization and with other exceptions pursuant to the law. To request this list, you must submit a written request. Your request must state a time period that may not be longer than six years. The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
Right to Request Restrictions
You have the right to request that we follow additional, special restrictions when using or disclosing your PHI for treatment, payment, or health care operations. You also have the right to request that we follow additional, special restrictions when using or disclosing your PHI to someone who is involved in your care or the payment for your health care, like a family member or friend. For example, you could ask that we not use or disclose that you are receiving services at this facility. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must submit a written request that tells us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.
Right to Request Confidential Communications
You have the right to request that we communicate with you about your appointments or other matters related to your treatment in a specific way or at a specific location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must submit a written request. Your request must specify how or where you wish to be contacted. We will not ask you the reason for your request. We will accommodate all reasonable requests.
Right to Receive Notification Regarding a Security Breach
As required by law, we must notify you within 60 days following the discovery of a security breach involving PHI. Additionally, a business associate must notify PromiseCare if a security breach occurs involving PHI. We will notify you, in writing, within 60 days, by first-class mail, if a security breach occurs that compromises the security or privacy of your PHI such that the use or disclosure poses a significant risk of financial, reputational, or other harm to you.
If we have insufficient or out-of-date contact information for you, we may contact you by telephone, post the breach Notice on the home page of our website or use major print or broadcast media where you are likely to reside. The breach notice will include, to the extent possible, a description of the breach, a description of the types of information that were involved in the breach, the steps affected individuals should take to protect themselves from potential harm, a brief description of what we are doing to investigate the breach, mitigate the harm, and prevent further breaches, as well as our contact information and a toll-free number for you to contact to determine if your PHI was involved in the breach.
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 if 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 the PromiseCare website: www.promisecare.com.
Right to Revoke Your Authorization
You have the right to revoke your authorization at any time for the use and disclosure of your PHI. To revoke your authorization to use and disclose your PHI you must submit a written request to PromiseCare at 1545 W. Florida Avenue, Hemet, California 92543, Attention Privacy Officer. The revocation will take effect when PromiseCare receives it, except to the extent that action has been taken in reliance upon it.
Changes to this Notice of Privacy Practices
We reserve the right to change the terms of this Notice. We reserve the right to make the revised or changed Notice effective for PHI we already have about you as well as any information we receive in the future. A copy of the current Notice is posted in our facility. The Notice contains the effective date at the top of first page. If we change our Notice, you may obtain a copy of the revised Notice by requesting one from our staff at our facility or by visiting our website at www.promisecare.com.
If you believe your privacy rights have been violated, you may file a complaint with us or the Federal Government. All complaints must be submitted in writing. You will not be penalized or retaliated against for filing a complaint. To file a complaint with us, or if you have comments or questions regarding our Privacy Practices, you may contact the following office:
Attention: Privacy Officer
1545 W. Florida Avenue Hemet, CA 92592
To file a complaint with the Federal Government, contact:
US Department of Health and Human Services Office for Civil Rights, Region IX
90 7th Street, Suite 4-100
San Francisco, California 94103
Phone: (415) 437-8310
TDD: (415) 437-8311
Fax: (415) 437-8329