Accountings will be limited to six years prior to the date of the request. You may be charged a fee for each subsequent accounting you request within the same 12-month period. The first accounting in any 12-month period is free. Requests must be made in writing and signed by you or your representative. This right does not apply to disclosures made for purposes of treatment, payment or healthcare operations. You have the right to receive an account of certain disclosures made by us of your protected health information. To request proxy access, complete the M圜hart authorization proxy access form. Patients may wish to grant other individuals proxy access to their M圜hart account. If you pay the entire bill for a service out-of-pocket, and you ask us not to send information about the specific service to your insurance for payment, we will honor this request as long as the information is not needed to explain other services for which your insurance will be billed. Health Information Management/Medical Records, 3535 Olentangy River Rd, Columbus, OH 43214. To request a restriction to your medical record please complete the patient request to limit uses and disclosures of personal health information form and return to: You also have the right to end any agreed-to restriction by sending written notice, signed by you or your representative. We retain the right to end an agreed-to restriction if we believe it’s appropriate. These services include outpatient medical record copy requests, record transfers, and release of medical information. In most cases, we are not required to agree to your restriction request, but will attempt to accommodate reasonable requests when appropriate. You may not limit the uses that we are allowed to do by law. You have the right to request limits on how we use and disclose your protected health information for treatment, payment or healthcare operations. To request an amendment to your medical record, complete the request to amend personal information form, attach the documentation from your medical record that you are requesting to be corrected, highlighting the areas on the document(s) that you believe are inaccurate and return to: If we make amendment or correction, we may also notify others who work with us and have copies of the uncorrected record if we believe it’s necessary. All amendment requests must be in writing, signed by you or your representative, and must state the reasons for the amendment or correction request to be considered. We are not obligated to make all requested changes, but will give each request careful consideration. If you believe there is a mistake in your protected health information or believe that information needs to be amended for accuracy, you have the right to request in writing that we amend or correct it for you.
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