Effective Date: November 2005
ALEGENT HEALTH
NOTICE OF PRIVACY PRACTICES

    YOUR RIGHTS REGARDING YOUR
    IDENTIFIABLE HEALTH INFORMATION

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

    • Confidential Communications. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. For example, you may ask that we contact you at work or by U.S. Mail. To request that we contact you in a certain way or at a certain location, you must make your request in writing to the Administrator of the facility at which you are receiving care or Alegent Health Privacy Office, 7101 Newport Ave, Suite 309, Omaha NE 68152. We will not ask you the reason for your request, and we will accommodate reasonable requests.

    Your written request must specify how or where you wish to be contacted. You must provide us with a mailing address where you can receive correspondence and other communications from us related to payment for the services you have received from us. Please realize, we reserve the right to contact you by other means and at other locations if you fail to respond to any communication from us that requires a response. We will notify you in accordance with your original request prior to attempting to contact you by other means or at another location.

    • Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your health information for treatment, payment or healthcare operations purposes. You also have the right to request that we limit our disclosure of your health information to individuals involved in your care or the payment for your care, such as family members and friends. Alegent Health is not required to agree to your request. NOTE: If we do agree, we will strive to comply with your request unless your information is needed to provide emergency treatment to you. However, Alegent Health cannot insure complete success.

    To formally request a restriction, you must make your request in writing to the Administrator of the facility at which you are receiving care or Alegent Health Privacy Office, 7101 Newport Ave, Suite 309, Omaha NE 68152. In your request, you must describe in a clear and concise fashion: (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, for example, disclosures to your spouse. Alegent Health does not have the authority to bind anyone else to any restrictions to which Alegent Health may agree.

    • Inspection and Copies. You have the right to inspect and copy health information that may be used to make decisions about your care, including your medical records and billing records, but not including psychotherapy notes. Alegent Health will respond to your request within thirty (30) days, unless state law requires us to respond earlier.

    To formally inspect or obtain a copy of health information that is maintained by or on behalf of Alegent Health and that may be used to make decisions about you, you must submit your request in writing to the medical record custodian of the facility at which you received care or Alegent Health Privacy Office at 6901 N 72nd Street, Omaha NE 68132-2512. Alegent Health may charge a fee for the costs of copying, mailing or other supplies associated with your request.

    We may deny your request to inspect and copy your health information under certain limited circumstances. For example, you may not be provided with your health information if it is determined that providing such information could cause harm to you or another person. In most cases, if you are denied access to health information you may request that the denial be reviewed. Alegent Health’s Chief Medical Officer in accordance with applicable law will review your request and the denial. The person conducting the review will not be the person who denied your request. The Alegent Health organization that originally denied you access will comply with the outcome of the review.

    • Amendment. If you feel that health information Alegent Health has 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 Alegent Health.

    To formally request an amendment of health information that is maintained by or on behalf of Alegent Health about you, your request must be made in writing and submitted to the medical record custodian of the facility at which you received care, or Alegent Health Privacy Office at 7101 Newport Ave, Suite 309, Omaha NE 68152. In addition, you must provide a reason that supports your request.

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

    • Is accurate and complete;
    • Was not created by Alegent Health, unless the person or entity that created the information is no longer
    • vailable to make the amendment;
    • Is not part of the health information kept by or for Alegent Health; or
    • Is not part of the information which you would be permitted to inspect and copy.

    • Accounting of Disclosures. You have the right to request an "accounting of disclosures." An accounting of disclosures is a list of certain disclosures Alegent Health has made of your identifiable health information. To request an accounting of disclosures made by Alegent Health, you must submit your request in writing to the medical record custodian of the facility at which you received care, or Alegent Health Privacy Office at 7101 Newport Ave, Suite 309, Omaha NE 68152. Your request must state a time period that may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12-month period will be free. For additional lists, you may be charged for the costs of providing the list. You will be notified of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

    • Right to a Paper Copy of This Notice. You have the right to receive a paper copy of this notice. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact Alegent Health Privacy Office at 6901 N 72nd Street, Omaha NE 68132-2512. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You also may obtain a copy of this notice at this link.