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Individual Rights

Access: You have the right to review or receive a copy of your medical information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. If we maintain your medical information in an electronic format, you may request and we shall provide you with the requested information in an electronic format. You must make a written request to obtain access to your medical information. You may obtain a form to request access or a copy of your medical information from memorialhermann.org web page and mail the completed form to 909 Frostwood, Suite 2.205, Houston, TX 77024 or the Release of Information department located at the facility where you obtain your medical care. There is a charge for a copy of your medical information.

Accounting of Disclosures: You have the right to receive an accounting of all disclosures of your medical information that was not authorized by you and that was not disclosed for the purpose of treatment, payment or health care operations. You must request this accounting in writing. You may request and we account for disclosures for a period of 6 years beginning on the date of the disclosure. You may download the Accounting of Disclosure Form from memorialhermann.org web page and mail the completed form to 909 Frostwood, Suite 2.205, Houston, TX 77024. You may also obtain the Accounting of Disclosure Form from the Release of Information Department located at the facility where you obtained your medical care.

Restrictions: You have the right to request that we place restrictions on our use or disclosure of your medical information. We are not required to agree to these restrictions; however, we will agree to your request not to disclose your medical information to a health plan for a particular item or service if the disclosure is to be made for payment or health care operation purposes and you have otherwise paid for the item or service in full. If we agree to your restriction request, we will abide by our agreement (except in an emergency). You must make this request in writing.

Confidential Communications: You have the right to request that we communicate with you about your medical information by alternative means or to alternative locations. You must make your request in writing. We must accommodate your request if: it is reasonable; specifies the alternative means or location; and provides a satisfactory explanation of how payments will be handled under the alternative means or location you request.

Amendment: You have the right to request that we amend your medical information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request if we did not create the information you want amended and the originator remains available or for certain other reasons. If we deny your request, we will provide you a written explanation. You may respond with a statement or disagreement to be appended to the information you want amended. If we accept your request to amend the information, we will make reasonable efforts to inform others; (including people you name) of the amendment and to include the changes in any future disclosures of that information.

Electronic Notice: If you view this Notice on our Web site or by electronic mail (e-mail), you are also entitled to receive a copy of this Notice in written form. Please contact us as directed below to obtain this Notice in written form.

Notice of a Breach: If there is a breach involving the privacy or security of your unsecured medical information, we will notify you, government officials and enforcement authorities, as necessary and appropriate, and we will take steps to address the issue and mitigate any damages that the breach may have caused.