Right to Request Information About You: You or your legally authorized representative are entitled to online access of documents available, review or receive paper copies, or request an electronic delivery of your health information. This includes your medical and billing information.

If you request a copy of your information, we may charge you for our costs. We will tell you in advance what this cost will be.

Right to Request to Amend or Supplement Information About You That You Believe is Incorrect or Incomplete: If when reviewing your medical records, you see health information you believe is incorrect or incomplete, you may ask us to amend your record. You may submit a request to amend your medical information by contacting Health Information Management at fmhrecords@foundationhealth.org or (907) 458-5450. You may complete the Request to Amend or Supplement Records form online.  Alternatively, our printable form can be found here. Or to amend your billing information, contact the Patient Financial Services/Business office at (907) 458-5510. 

Right to Get a List of Certain Disclosures of Information About You: You have the right to request a list of certain disclosures we made of information about you. For SUD records specifically (as described below), you have the right to receive an accounting of disclosures of your SUD records for the last 3 years. If you would like to receive such a list, contact Health Information Management at fmhrecords@foundationhealth. org or (907) 458-5450. We will provide the first list to you at no charge, but we may charge you for any additional lists you request during a twelve-month period. We will tell you in advance what this list will cost.  

Right to Request Restrictions on How FHP Will Use or Disclose Information About You for Treatment, Payment, or Health Care Operations: You have the right to request us not to use or disclose information about you to treat you, to seek payment for care, or to operate the health care system. We are not required to agree to your request, but if we do agree, we will comply with that agreement unless that information is necessary to provide you emergency treatment.

You may request that we withhold information from your health plan for the purpose of payment or health care operations provided it is not otherwise required by law. If you want to request a restriction to your medical information, you may contact Health Information Management or for billing information, you may contact the Business Office.

You have the right to pay for an item or service and elect not to have this information about you submitted to your health plan. We are not required to accept your request until you have paid for this service or item. We are not required to notify other health care providers of these types of restrictions, this is your responsibility.

If you want to request a restriction to your medical information, contact Health Information Management at (907) 458-5450. To request a restriction to your billing information, contact the Patient Financial Services/ Business Office at (907) 458-5510.

Right to Choose Someone to Act for You: If someone has authority to act as your personal representative, such as if someone has your medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.

Right to Request Confidential Communications: You have the right to request us to communicate with you in a way that you feel is more confidential. You can ask to speak with your health care providers in private, outside the presence of other patients. We will accommodate reasonable requests including alternative addresses or alternative means. For example, you can ask us not to call your home, but to communicate only by mail. To do this, submit your request in writing to Health Information Management at fmhrecords@foundationhealth.org or (907) 458-5450.

Right to a Copy of FHP’s Notice of Privacy Practices:
 You have the right to a paper copy of the Notice at any time. You may obtain a copy of the Notice from our web site at www.foundationhealth.org or you may obtain a paper copy of the Notice at patient registration sites.

Right to Submit Complaints: If you suspect that your rights have been violated under HIPAA, 42 CFR Part 2, or any other federal or state privacy law, you have the right to submit a complaint with us by using the contact information at the end of this form and/or with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting https://www.hhs.gov/hipaa/filing-a-complaint/index.html. You will never be retaliated against for filing a complaint.

Our Responsibilities Regarding Your Records

We are required to:

• Obtain your consent for most uses and sharing of your information.
• Maintain the confidentiality of your health information in accordance with this notice of privacy practices, HIPAA, and 42 CFR Part 2.
• Comply with stricter protections when they apply.
• Notify you of your privacy rights and our legal duties relating to your health information in this notice and provide you with a copy of it.
• Notify you if there has been a breach of your unsecured records that may have compromised the privacy or security of your information.
• Provide contact information and implement a system that allows you to contact someone from FHP or another appropriate contact individual regarding questions, comments, requests, concerns, or complaints  dealing with your health information or this notice.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.