Other Uses of Medical Information Require an Authorization: Other uses and disclosures of medical information not covered by this Notice or the laws that apply to City Urgent Care will be made only with your written authorization. If you provide City Urgent Care an authorization to use or disclose medical information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, City Urgent Care will no longer use or disclose medical information about you for the reasons covered by the written authorization. You understand that City Urgent Care is unable to take back any disclosures we have already made with your authorization and that we are required to retain our records of the care that we provide you.
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU: You have many rights with regard to your medical information. If you wish to exercise any rights, you must submit your request in writing, unless otherwise noted.
Your Right to Inspect and Copy: You have the right to inspect and copy medical information that may be used to make decisions about your care. City Urgent Care may charge a reasonable fee for the costs of copying, mailing, or other supplies associated with your request.
Your Right to Amend: If you feel that the medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to add a statement. You must provide a reason that supports your request for an amendment. Your right to an Accounting and Disclosures: You have the right to request an "accounting of disclosures." This is a list of certain disclosure City Urgent Care made of medical information about you. Your request must state a time period. We may limit the time period to 6 years and to disclosures made after April 14, 2003. The first list you request within a 12-month period is free. For additional lists, we may charge you for the costs of providing the list.
Your Right to Request Confidential Communication: You have the right to request that City Urgent Care communicates with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. If we maintain medical information about you in electronic format, you also have the right to obtain a copy of such information in electronic format and to direct us to transmit such information directly to an entity or person clearly, conspicuously, and specifically designated by you. We will not ask you the reason for your request. You may make this request in writing or verbally.
Your Right to Request Restrictions: You have the right to request a restriction or limitation on the medical information City Urgent Care uses or discloses about you. For any services for which you paid out-of-pocket in full, we will honor any request you make to restrict information about those services from your health plan, provided that such release is not necessary for your treatment. In all other circumstances, we are not required by law not agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
Right to 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. Right to File a Complaint: If you believe your rights have been violated, you may file a complaint with us. You may also file a complaint directly with the Secretary of the Department of Health and Human Services. You will not be penalized in any way for filing a complaint.
Changes to This Notice: City Urgent Care reserves the right to change this Notice. We reserve the right to make revised or changed Notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current Notice at our offices and make copies available upon request.
Privacy Notice Contact Information: City Urgent Care is required by law to maintain the privacy of, and provide individuals with this notice of our legal duties and privacy practices with respect to protect health information. If you have any objections to this form, please contact our office manager at (313)308-2444.