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Your Health Information Rights

Although your medical record is the physical property of Sansum Clinic, the information that it contains belongs to you. As a result, you have the following rights regarding the health information that we maintain about you:

  • You have the right to obtain a paper copy of our Notice of Privacy Practices for Protected Health Information upon request. Upon signing the General Consent for Treatment form at registration, you are provided a copy of this Notice to read and take home with you. A copy of this Notice is also posted at all Sansum Clinic locations and on our website, sansumclinic.org. Even if you have obtained this Notice in another form, or at another time, you are still entitled to a paper copy of this Notice upon request.
  • You have the right to inspect a copy of your medical record. You have the right to inspect medical information that may be used to make decisions about your care. This includes medical and billing records but may exclude certain mental health information (e.g., psychotherapy notes). To view your medical record in person, you must submit a request in writing to the Sansum Clinic Health Information Services (HIS) Department (Attention: Release of Information/ Correspondence), 317 West Pueblo Street, Santa Barbara, CA 93105. You will obtain a response regarding your request within 5 business days, after which you may come to the Correspondence Office to inspect your records in person. In some limited circumstances, your provider may deny your request to inspect your medical record and you would be notified of this denial in writing with an explanation of the basis for the denial. In such cases, you may request that your denial be reviewed. Another licensed health care professional chosen by Sansum Clinic will review both your request and the denial. Sansum Clinic will be bound by the outcome of this secondary review.
  • You have the right to obtain a copy of your medical record. You may request a copy of your medical record by submitting an Authorization to Release Medical Information form to the Sansum Clinic Health Information Services (HIS) Department (Attention: Release of Information/ Correspondence), 317 West Pueblo Street, Santa Barbara, CA 93105. There are fees involved in providing you a paper-based copy for your personal use depending on how you would like your record delivered to you. However, there are no charges involved if the copy is to go directly from the ROI/ Correspondence Office to your physician or other health care provider. Your request will be processed within 15 business days, and you will be notified as soon as your copy is ready. As outlined above, a request to obtain a copy of certain mental health information may be denied by your provider and you will be notified regarding that denial within 5 business days from receipt of your request.
  • You also have the right to make an addendum or request an amendment to the information in your health record. If you believe that medical information we have about you is incorrect or incomplete, you may provide us a written addendum to any item or statement in your medical record or you may ask us to amend the information. To file a written addendum, you must fill out a Request to File an Addendum to Protected Health Information form. To request an amendment, you must complete a Request to Amend Protected Health Information form. The applicable form can be submitted by mail, by fax (805-898-3428), or in person to the Sansum Clinic HIS Department, (Attention: ROI/ Correspondence), 317 West Pueblo Street, Santa Barbara, CA 93105. Be sure to include your reason for requesting the addendum or amendment. If your request is not in writing or does not state any reason to support your request, we may have to deny it. In addition, we may deny your request if you ask us to change information that:
    • Was not originated by Sansum Clinic, unless the person or entity that generated the information is no longer available to make the amendment.
    • Is not part of the medical record (your PHI) kept by Sansum Clinic.
    • Is not part of the information which you would be permitted to inspect and/ or copy under Sansum Clinic policy.
    • Is accurate and complete as is.

You will receive a response from the ROI/ Correspondence Office regarding your request within 15 days following receipt.

  • You have the right to revoke your authorization to use or disclose health information at any time except to the extent that the information has already been used or disclosed. For example, Sansum Clinic may obtain your written authorization to use or disclose your health information for purposes other than treatment, payment or health care operations (e.g., you may sign an authorization allowing Sansum Clinic to disclose your protected health information to a life insurance company in order to obtain life insurance coverage). Any authorization you provide to us regarding the use and/or disclosure of your health information may be revoked at any time. You must submit your request in writing to the Sansum Clinic HIS Department (Attention: ROI/ Correspondence Office), 317 West Pueblo Street, Santa Barbara CA 93105. Your request shall be processed within 15 business days following receipt. After you revoke your authorization we will no longer use or disclose your health information for the purposes described in the authorization.
  • You have the right to obtain an "accounting of disclosures" of your health information. An accounting of disclosures is a list of certain non-routine disclosures that Sansum Clinic has made of your health information for purposes other than treatment, payment or health care operations and for which you did not sign an authorization form. Examples of non-routine disclosures include disclosures made to law enforcement or public health officials. In order to obtain an accounting of disclosures, you must obtain and complete a Request for an Accounting of Disclosures of Protected Health Information form available at every Sansum Clinic location. You may submit this form by mail, by fax (805- 898 3428), or in person to the Sansum Clinic HIS Department, (Attention: ROI/ Correspondence Department), 317 West Pueblo Street, Santa Barbara CA 93105. The request 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. Your request shall be processed within 30 days from receipt. The first list you request within a twelve-month period is free of charge, but Sansum Clinic will charge for additional lists within the same twelve-month period.
  • You have the right to request a restriction on certain uses and disclosures of your health information. You have the right to request a restriction or limitation on the medical information we use or disclose about you. Additionally, you have the right to request that we restrict our disclosure of your health information to only certain individuals involved in your care, such as family members or friends. For example, you may ask that we not use or disclose information about a surgery or treatment that you had at Sansum Clinic to anyone other than your daughter. Sansum Clinic is 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 of Sansum Clinic's use or disclosure of your health information, you must obtain and complete a Request for Special Restriction on Use or Disclosure of Protected Health Information form and submit this form by mail, by fax (805-898 3428), or in person to the Sansum Clinic HIS Department, (Attention: ROI/ Correspondence Department), 317 West Pueblo Street, Santa Barbara CA 93105. The request must describe (a) the information you wish restricted, (b) whether you are requesting to limit Sansum Clinic's use, disclosure or both, and (c) to whom you want the limits to apply. Your request shall be processed within 30 days from receipt.
  • You have the right to request that Sansum Clinic communicate with you about your health and related issues in a particular manner or at a certain location (e.g., you may ask that we contact you at home, rather than at work). In order to request a type of confidential communication, you must obtain and complete a Request for Restriction on the Manner/ Method of Confidential Communications form and submit it by mail, by fax (805-898-3428), or in person to the Sansum Clinic HIS Department, (Attention: ROI/ Correspondence Department), 317 West Pueblo Street, Santa Barbara CA 93105. Your request should specify the requested method of contact, or the location where you wish to be contacted. Sansum Clinic will accommodate all reasonable requests. You do not need to give a reason for your request. However, your request must be clear and specific as to how, when and where you wish to be contacted. Your request shall be processed within 30 days from receipt.
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