the extent that the Hospital and/or Health Professionals have taken action in reliance upon it, by delivering a written revocation statement to the Hospital Health Information Management Office identified below.
Right to Inspect and Copy Your Health Information. You may request access to your medical record file and billing records maintained by the Hospital and Health Professionals in order to inspect and request copies of the records. Under limited circumstances, you may be denied access to a portion of your records. If you desire access to your records, please obtain a record request form from the Hospital Health Information Management Office and submit the completed form to the Hospital Health Information Management Office. If you request copies of paper records, you will be charged in accordance with federal and state law. To the extent the request for records includes portions of records which are not in paper form (e.g., x-ray films), you will be charged the reasonable cost of the copies. You also will be charged for the postage costs, if you request that the copies be mailed to you. However, you will not be charged for copies that are requested in order to make or complete an application for a federal or state disability benefits program.
Right to Amend Your Records. You have the right to request that PHI maintained in your medical record file or billing records be amended. If you desire to amend your records, please obtain an amendment request form from the Hospital Health Information Management Office and submit the completed form to the Hospital Health Information Management Office. Your request will be accommodated unless the Hospital and/or Health Professionals believe that the information that would be amended is accurate and complete or other special circumstances apply.
Right to Receive an Accounting of Disclosures. Upon request, you may obtain an accounting of certain disclosures of your PHI made during any period of time prior to the date of your request provided such period does not exceed six years and does not apply to disclosures that occurred prior to April 14, 2003. If you request an accounting more than once during a twelve (12) month period, you will be charged for the accounting statement.
Right to Receive Paper Copy of this Notice. Upon request, you may obtain a paper copy of this Notice, even if you have agreed to receive such notice electronically.
For Further Information or Complaints. If you desire further information about your privacy rights, are concerned that your privacy rights have been violated or disagree with a decision
made about access to your PHI, you may contact the Hospital Compliance & Privacy Off ice. You may also f ile written complaints with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services. Upon request, the Hospital Compliance & Privacy Office will provide you with the correct address for the Director. The Hospital and Health Professionals will not retaliate against you if you file a complaint with the Hospital Privacy Office or the Director.
Effective Date and Duration of This Notice Effective Date. This Notice is effective on September 23, 2013.
Right to Change Terms of this Notice. The terms of this Notice may be changed at any time. If this Notice is changed, the new notice terms may be made effective for all PHI that the Hospital and Health Professionals maintain, including any information created or received prior to issuing the new notice. If this Notice is changed, the new notice will be posted in waiting areas around the Hospital and on our Internet site at
www.SPHN.com. You also may obtain any new notice by contacting the Hospital Compliance & Privacy Office.
HOSPITAL CONTACTS: You may contact the Hospital Compliance & Privacy Office at:
Compliance & Privacy Office Sierra Medical Center Sierra Providence Health Network 1625 Medical Center Drive, El Paso Texas 79902 Telephone Number: 915-577-7533 or 577-2962 E-mail:
PrivacySecurityOffice@tenethealth.com
Corporate Compliance & Privacy Office Tenet Healthcare 1445 Ross Avenue, Suite 1400 Dallas,Texas 75202 E-mail:
PrivacySecurityOffice@tenethealth.com Phone: 1-877-893-8363 ext. 2009 Ethics Action Line (EAL): 1-800-8-ETHICS
You may contact the Medical Records or Health Information Management Office at:
Medical Records or Health Information Management Office Sierra Medical Center 1625 Medical Center Drive, El Paso, Texas 79902 El Paso, Texas 79902 Telephone Number: 915-747-2681 E-mail:
Sarah.Arzaga@
tenethealth.com
www.sphn.edu 915-747-4000 : 23
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