Inspection and Copies:  You have the right to inspect and obtain a copy of the health information that may be used to make decisions about you, including patient health records and billing records. You may also request that your records be sent to another person(s) or provider of health care. You must submit your request in writing to Mammoth Hospital, Health Information Management Services, Release of Information, P.O. Box 660, Mammoth Lakes, CA 93546, (760) 934-3311 ext. 2378 in order to inspect and/or obtain a copy of your health information. Mammoth Hospital may charge a fee for the costs of copying, mailing, labor and supplies associated with your request.

Mammoth Hospital may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed health care professional chosen by us will conduct reviews.

Authorization to Disclose Health Information
   Autorización para proporcionar información médica

REQUEST FOR LIMITATIONS & RESTRICTIONS OF PHI Form
Requesting Restrictions:  You have the right to request a restriction in our use or disclosure of your health information for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your health information to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your health information, you must make your request in writing to Mammoth Hospital, Privacy Officer, P.O. Box 660, Mammoth Lakes, CA 93546. Your request must describe in a clear and concise fashion (1) the information you wish restricted; (2) whether you are requesting to limit our practice’s use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.

Request for Limitations & Restrictions of Protected Health Information Form
    Solicitud De Limitaciones Y Restricciones De La Información Protegida Concerniente A La Salud

REQUEST FOR CORRECTION/AMENDMENT OF HEALTH INFO Form
Amendment:  You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for Mammoth Hospital. To request an amendment, your request must be made in writing and submitted to Mammoth Hospital, Privacy Officer, P.O. Box 660, Mammoth Lakes, CA 93546. You must provide us with a reason that supports your request for amendment.  Mammoth Hospital will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the health information kept by or for the practice; (c) not part of the health information which you would be permitted to inspect and copy; or (d) not created by our practice, unless the individual or entity that created the information is not available to amend the information.

Even if we deny your request for amendment, you have the right to submit a written addendum, not to exceed 250 words, with respect to any item or statement in your record you believe is incomplete or incorrect.  If you clearly indicate in writing that you want the addendum to be made part of your health record we will attach it to your records and include it whenever we make a disclosure of the item or statement you believe to be incomplete or incorrect.

Request for Correction/Amendment of Health Information Form
    Solicitud de corrección o enmienda de información concerniente a la salud

REQUEST FOR RESTRICTION ON THE MANNER/METHOD OF CONFIDENTIAL COMMUNICATIONS Form
Confidential Communications:   You have the right to request that Mammoth Hospital communicate with you about your health and related issues in a particular manner or at a certain location. For example, you may ask that we contact you at home, rather than work. In order to request a type of confidential communication, you must make a written request to Mammoth Hospital, Privacy Officer, P.O. Box 660, Mammoth Lakes, CA 93546 specifying the requested method of contact, or the location where you wish to be contacted. Our practice will accommodate reasonable requests. You do not need to give a reason for your request.

Request for Restriction on the Manner/Method of Confidential Communications Form
    Solicitud De Restricción En La Forma O En El Método De Envío De Comunicaciones Confidenciales

REQUEST FOR ACCOUNTING OF DISCLOSURE Form
Accounting of Disclosures:  All of our patients have the right to request an “accounting of disclosures.” An “accounting of disclosures” is a list of certain non-routine disclosures our practice has made of your health information for non-treatment or operations purposes. Use of your health information as part of the routine patient care in Mammoth Hospital is not required to be documented. For example, a doctor sharing information with the nurse; or the billing department using your information to file your insurance claim. In order to obtain an accounting of disclosures, you must submit your request in writing to Mammoth Hospital, Health Information Management Services, Release of Information, P.O. Box 660, Mammoth Lakes, CA 93546. All requests for an “accounting of disclosures” must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003. The first list you request within a 12-month period is free of charge, but our practice may charge you for additional lists within the same 12-month period.

Mammoth Hospital will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.

Request for Accounting of Disclosure Form
    Solicitud Del Estado De Cuenta De Revelaciones De Informacion Protegida De Su Salud