Rights to Accounting of Disclosures
You have the right to request an “accounting of disclosures.” This is a list of certain disclosures we made of medical information about you. To request an accounting of disclosures, you must submit your request in writing to our Privacy Officer.
Rights to Request Restrictions
You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or 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 for your care, like a family member or friend. 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 emergency treatment.
To request restrictions, you must make your request in writing to your Privacy Officer at the address below. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) 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 at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to our Privacy Officer. We will not ask you the reason for your request. 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 the right to a paper 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. To obtain a paper copy of this notice, please request one in writing from our Privacy Officer at the address below.
CHANGES TO THIS NOTICE
We have 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 as well as any information we receive in the future. We will post a copy of the current notice. The notice will contain on the first page, in the top right-hand corner, the effective date.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with the Penn Medicine Becker Ear, Nose, and Throat Center or with the Secretary of the Department of Health and Human Services. To file a complaint with the Penn Medicine Becker Ear, Nose, and Throat Center, contact our Privacy Officer at the address and phone number listed below. 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, thereafter 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 to you.
PRIVACY OFFICER 1-856-589-6673
Penn Medicine Becker ENT Center
570 Egg Harbor Road Suite B-2
Sewell, NJ 08080
