YOUR RIGHTS
1. Restrictions
on Use and Disclosure of Individual Health Information. You have
the right to request restrictions on some of our uses and disclosures
of your health information. These restrictions must be made in writing
and signed by you or your representative. This office is not required
to agree to your restrictions. We retain the right to terminate an agreed-to
restriction if we believe such termination is appropriate. In the event
of a termination by us, we will notify you of such termination. You also
have the right to terminate, in writing or orally, any agreed-to restriction
by sending such termination notice to Privacy Officer, 1 Park
West Boulevard, Suite 200, Akron, Ohio 44320.
2. Access to Individual Health Information. You have the right
to inspect and copy your health information maintained by this office.
All requests for access must be made in writing and signed by you or your
representative. A fee of $.50 per page if you request
a copy of the information. There will also be a charge for postage if
you request a mailed copy and, if requested, for preparation of a summary
of the requested information. (charge not to exceed $15.00) You may obtain
a request for access form from Privacy Officer, 1 Park West Boulevard,
Suite 200, Akron, Ohio 44320. In certain
circumstances, you may not be permitted access (e.g., psychotherapy notes,
information compiled for legal action, or information subject to prohibition
by law). Depending on the circumstances, you may request a review
of the decision to deny access. Please contact the Privacy Officer
for questions about access to your health information.
3. Amendments
to Individual Health Information. You have the right to request in
writing that your health information maintained by this office be amended
or corrected. In certain cases, we may deny your request for amendment.
All amendment requests must be in writing, signed by you or your representative,
and must state the reasons for the amendment. If we make an amendment,
we may also notify others who work with us and have copies of the un-amended
record if we believe that such notification is necessary. You may obtain
an amendment request form from Privacy Officer, 1 Park West Boulevard,
Suite 200, Akron, Ohio 44320. If we deny your request,
you may submit a statement of disagreement to us and we may prepare a
rebuttal that will be provided to you. These materials may be distributed
in future requests to review your health information. Please contact the
Privacy Officer for questions about amendments to your
health information.
4. Accounting for Disclosures of Individual Health Information. You
have the right to receive an accounting of certain disclosures made by
us of your health information after April 14, 2003. Requests must be made
in writing and signed by you or your representative. Accounting request
forms are available from Privacy Officer, 1 Park West Boulevard,
Suite 200, Akron, Ohio 44320. The first accounting in any 12-month
period is free; you will be charged a fee of $5.00 for
each subsequent accounting you request within the same twelve-month period.
The right to receive this information is subject to certain exceptions,
restrictions, and limitations.
COMPLAINTS:
If you believe your privacy rights have been violated, you may
file a complaint with
Privacy Officer, 1 Park West Boulevard, Suite 200, Akron, Ohio
44320 in writing or file a complaint with the Secretary of the
U.S. Department of Health and Human Services in Washington D.C. in writing.
There will be no retaliation for filing a complaint.
ADDITIONAL INFORMATION
If you have questions or need additional assistance regarding
this Notice, you may contact Privacy Officer, Paragon Health Associates,
LLC, 1 Park West Boulevard, Suite 200, Akron, Ohio 44320, confidential
telephone number: 330-869-9777.
