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operations. Even if the Plan agrees to your request for a restriction, there are exceptions. For example, if you
need emergency treatment, restricted information may be used or disclosed if it is needed for your treat-
ment. Additionally, there are certain instances in which uses and disclosures cannot be restricted. For exam-
ple, if disclosure is required by law, a restriction would not apply. You may terminate any restriction that you
have requested. The Plan may also terminate any restriction it agreed to without your approval. A termina-
tion by the Plan will affect only new information – in other words, information created or received by the Plan
after the termination.
You may also request that your health care provider not disclose your PHI to the Plan for a health care item
or service if you have paid for the item or service out-of-pocket in full. Please note that if your health care
provider does not disclose the item or service to the Plan, the amount you paid for the item or service will not
count toward your annual deductible or any out-of-pocket maximums under the Plan. The provider may also
charge you the out-of-network rate for the item or service.
You have a right to receive confidential (alternative) communications of PHI.
You may request that PHI be communicated to you at an alternate address or by alternate means if your re-
quest clearly states that you could be endangered by disclosure of all or part of your PHI. Your request must
be made in writing and must specify an alternate address or method of contact. The Plan will accommodate
reasonable requests, though it will require that any alternative used still allow for payment information to be
effectively communicated and for payments to be made.
You have the right to access or copy your PHI.
You have a right to inspect and copy certain PHI maintained by the Plan. Remember that your health care
provider has the most complete records of your health care, including information the Plan does not have,
use or maintain.
We recommend that you contact your provider to review your health information. If you want to see the in-
formation maintained by the Plan, you must make the request in writing to
the Plan’s Privacy Official
using
the contact information at the end of this notice. The Plan may charge a cost-based fee for supplies, labor
and postage. If you ask for a summary or explanation of your personal health information, the Plan may
charge you for the cost of preparing the summary or explanation.
Your right of access is limited. For example, you do not have the right of access to psychotherapy notes, to
information used in judicial or administrative proceedings or to information that is subject to the federal Pri-
vacy Act or under a promise of confidentiality. The Plan may deny you access to your PHI in the Plan’s rec-
ords. You may, under some circumstances, request a review of that denial.