YOUR RIGHTS CONCERNING MEDICAL INFORMATION ABOUT YOU

You have the following rights regarding medical information we maintain about you:

• Right to Inspect and Copy: You have the right to inspect and get a copy of medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes.

  To inspect and get a copy of medical information that may be used to make decisions about you, you must submit your request in writing to the Medical Records Department of Cascade Valley Hospital (for the hospital and surgery center) or to the Clinic Process Coordinator of any of our clinics.

  We may deny your request to inspect and copy your record in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by the organization will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

• Right to Amend: If you think the medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for us. To request an amendment, your request must be made in writing and submitted to our Privacy Officer. In addition, you must supply a reason that supports your request.

  We may deny your request for an amendment if it is not in writing or does not include a reason to support your request. In addition, we may also deny your request if you ask us to amend information that:

  1. was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
  2. is not part of the medical information kept by or for our facilities;
  3. is not part of the information which you would be permitted to inspect and copy; or
  4. is accurate and complete.
  
  

• Right to an Accounting of Disclosures: You have the right to request an "accounting of disclosures". This is a list of the disclosures we made of medical information about you.

  To request this list, or accounting of disclosures, you must submit your request in writing to the Medical Records Department of the hospital (and for the srugery center), or to the Clinic Process Coordinator of any of our clinics. Your request must state a time period which may not be longer than six years, and may not include dates before April 14, 2003. The first list you request in any twelve-month period will be free of charge. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request before any costs are incurred.

• Right to Request Restrictions: You have the right to request a restriction or limitation on the medical information that we use or disclose about you for treatment, payment of health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care, or the payment of your care. For example, you could ask that we not use or disclose information about a surgery that you had.

  We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment.

  To request restrictions, you must submit your request in writing to our Privacy Officer. In your request, you must tell us what information you want to limit, whether you want to limit our use, our disclosure, or both, and to whom you want the limits to apply.

• Right to Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or in a certain location. For example, you can ask that we only contact you at work, or by mail.

  To request confidential communications, you must notify the Admitting Representative or Patient Service Representative when you register. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

• Right to a Paper Copy of this Notice: You have a right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice at our website, at www.cascadevalley.org. To obtain a paper copy of this notice, contact the Admitting Department at Cascade Valley Hospital or any receptionist at any of our clinics or surgery center.

Changes to this Notice
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you, and for information we receive in the future. We will post a copy of the current notice in the hospital, each clinic and the surgery center. The notice will contain the effective date on the top of each page.

The first time you register at the hospital, surgery center or a clinic, we will offer you a copy of the notice currently in effect.

Complaints
If you believe your privacy rights have been violated, you may file a complaint with the Privacy Officer or with the Secretary of the Department of Health and Human Services. To file a complaint with the Privacy Officer, contact:

Privacy Officer
Cascade Valley Hospital and Clinics
330 So. Stillaguamish Avenue
Arlington, WA 98223
360-435-2133, extension 4900.

All complaints must be submitted in writing.

You will not be penalized for filing a complaint.

Other uses of medical information
Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided you.