Advanced Diagnostic Imaging

OTHER USES AND DISCLOSURES OF HEALTH INFORMATION

A/WDI is required to obtain written authorization from you for any uses and disclosures of Health Information other than those described above. If you provided A/WDI with such permission, you may revoke that permission, in writing, at any time. If you revoke your permission, A/WDI will no longer use or disclose personal information about you for the reasons covered by your written authorization. A/WDI cannot be held responsible for valid disclosures of Health Information made under an effective authorization prior to your revocation of that authorization.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

Right to Request Restrictions: You have the right to ask for restrictions on the ways in which A/WDI uses and disclose your Health Information beyond those imposed by law. A/WDI will consider your request, but is not required to accept it.

Right to Request Alternative Delivery of Information: You have the right to request that you receive communications containing your Health Information from A/WDI by alternative means or at alternative locations. For example, you may ask that we only contact you at home or by mail. A/WDI is not required to accept any such requests that are unreasonable.

Right to Inspect and Copy: Except under certain circumstances, you have the right to inspect and copy medical and billing records used to make decisions about your care. If you ask for copies of this information, A/WDI may charge you a fee for copying and mailing. Under some circumstances, if A/WDI denies your request to inspect your records, you may request in writing that the denial be reviewed.

Right to Amend Information: If you believe that information in your records is incorrect or incomplete, you have the right to request, in writing, that A/WDI correct the existing information or correct the missing information. Under certain circumstances, we may deny your request.

Right to an Accounting of Disclosures: You have a right to ask for a list of certain instances when A/WDI has used or disclosed your Health Information for reasons other than your treatment (by A/WDI or other health care providers), payment for services furnished to you (by A/WDI or other healthcare providers), A/WDI’s health care operations, certain health care operations of other entities or disclosures you give us authorization to make. The first list requested in any 12-month period will be free. If you ask for this information from us more than once every twelve months, we may charge you a fee.

To Exercise Any of Your Rights, Please Contact A/WDI in Writing at:

Advanced/Wabash Diagnostic Imaging
Attn: Jane Harvey, Privacy Officer
328 N. Second Street, Suite 101
Vincennes, IN 47591

CHANGES TO THIS NOTICE

A/WDI reserves the right to make changes to this notice at any time. A/WDI reserves the right to make the revised notice effective for Health Information A/WDI has about you as well as any information A/WDI receives in the future. In the event this authorization is revised, a copy of the revised version will be supplied to you upon your first visit after the effective date of the new version. A copy of the new version will also be posted in a public area of each of A/WDI’s locations, on A/WDI’s website, and in hard copy from any of A/WDI’s locations. In addition, you may request a copy of the revised Notice at any time.

COMPLAINTS/COMMENTS

If you have any complaints concerning our Privacy Policy, you may contact our Privacy Officer by phone at 812-882-8252 or by mail at Advanced/Wabash Diagnostic Imaging, 328 North Second Street, Suite 101, Vincennes, IN 47591. You also may contact the Secretary of the Department of Health and Human Services, at 200 Independence Avenue, S.W., Room 509F, HHH Building, Washington, D.C. 20201 (e-mail: ocrmail@hhs.gov). A/WDI is prohibited from interfering with your right to file a compliant regarding A/WDI’s privacy practices and can not retaliate against you in any way based on your filing of such a complaint.

To obtain more information concerning this Notice of Privacy Practices, you may contact A/WDI’s Privacy Officer, Jane Harvey, at 812-882-8252 or by mail at Advanced/Wabash Diagnostic Imaging, 328 North Second Street, Suite 101, Vincennes, IN 47591.

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