Your Rights:

You have a right to request a restriction on certain uses and disclosures of your PHI; inspect and copy your PHI; request amendments to your PHI; and obtain an accounting or list of disclosures of your PHI. This access does not include records from outside agencies, such as hospitals, DOR, etc. Such access to the file must be authorized by the Program Director, with a notation of date and time entered in the file. If it is felt that, it would not be in the best interest of the member to access the file, a written summary of the file contents will be provided to the individual. A staff member must be present while the record is being reviewed by the member to ensure that nothing is removed or changed within the file contents. A member who disagrees with the contents of his/her records will have the opportunity to submit corrections/amendments, which would be included in the records.

Our Duty: It is our duty to provide you with a copy of this disclosure statement for your personal records at the point of intake. A duplicate can be provided for you at any time upon request.

For More Information or to Report a Problem: If you have questions or concerns regarding our privacy practices, feel free to contact Bright Future Community Health Care Services.

Acknowledgement: Please sign below to indicate that you have received a copy of the Confidentiality & Privacy Practices Disclosure Statement.