Right to Access and Copy Records: You have the right to inspect and copy your PHI by using a written request form and submitting such form to our office. There are limited exceptions to this right. Upon your request, you may receive this information in an electronic format if such a copy is readily producible. You may be charged a reasonable fee for the cost of copying your records, as mentioned in our payment plans. Amendment: You have the right to amend your PHI, if you feel it is inaccurate or incomplete. Your request must be made to our office in writing and must include an explanation of why the information should be amended. Under certain circumstances, your request may be denied. Right to an Accounting of Disclosures: You have the right to request an “account of disclosures” of your PHI. This is a list of disclosures we made of PHI about you, other than for Treatment, Payment or Health Care Operations as described in this Notice. We are not required to account for information releases that you request, that you agree to by signing an authorization form, or certain releases that we are allowed to make without your permission. The request for an accounting must be made in writing to our office. The request should state the time period for the accounting. Requests for records about our disclosures of your PHI are limited to a time period as required by law. You may be charged a fee for the cost of compiling this accounting. Right to Request Limits on Use or Disclosure of PHI: You have the right to request that we place additional restrictions on our use or disclosure of your PHI. We do not have to agree to these additional restrictions unless you request us not to disclose PHI to your health plan with respect to a health care item or service for which you have paid in full out of pocket. If we do agree to such restriction, we will abide by our agreement unless the PHI is needed to provide you with emergency treatment. Please contact our office if you want to further restrict access to your health care information. This request must be submitted in writing. Right to Choose How We Communicate with You: You have the right to request that we communicate 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. To request confidential communications, you must make a request in writing to our office. Your request must specify how or where you wish to be contacted. We will not ask you the reason for the request. We will attempt to accommodate all reasonable requests. Right to Receive Notifications of Data Breach: You have the right to and will receive notification of breaches of your unsecured PHI. HIPAA Notice of Private Practice This Form Does NOT Constitute Legal Advice. Please Consult a Qualified Attorney, if necessary.