HIPAA Privacy Rights Forms

Complaint Form	Last Updated: 12/2005
As required by the Health Information Portability and Accountability Act of 1996 (HIPAA) you have a right to complain about UCAR's privacy policies, procedures or actions. UCAR will not engage in any discriminatory or other retaliatory behavior against you because of this complaint. Please be as thorough and forthright as possible, and return it to UCAR's Contact Person listed on the form.
Confidential Communication Request Form	Added: 4/2003
As required by the Health Information Portability and Accountability Act of 1996 (HIPAA) you have a right to request that communications concerning your personal health information be made through confidential channels. UCAR will not ask you why you are making your request, and will try to accommodate all reasonable requests.
Request for Access	Added: 4/2003
As required by the Health Information Portability and Accountability Act of 1996 (HIPAA) you have a right to request the opportunity to inspect and copy health information that pertains to you. We will evaluate your request and will either grant it or explain the reason why the request will not be granted. Your right to access does not extend to information compiled in reasonable participation of, or for use in, a civil, criminal or administrative action or proceeding, or to information we received in confidence from someone other than another health care provider.
Request for Amendment	Added: 4/2003
As required by the Health Information Portability and Accountability Act of 1996 (HIPAA) you have a right to request that health information that pertains to you be amended if you believe that it is incorrect or incomplete. We will review your request and either grant your request or explain the reason why it will not be granted. In the event that your request is not granted, you have the right to submit a statement of disagreement that will accompany the information in question for all future disclosures.
Request for Disclosure Accounting	Added: 4/2003
As required by the Health Information Portability and Accountability Act of 1996 (HIPAA) you have a right to request an accounting of disclosures of health information that pertains to you.
Request for Special Privacy Protections	Added: 4/2003
As required by the Health Information Portability and Accountability Act of 1996 (HIPAA) you have a right to request that we restrict our uses and disclosures of your protected health information with respect to treatment, payment and health care operations. You also have a right to request that we restrict our uses and disclosures of your health information with respect to disclosures to members of your family and other relatives or close personal friends or other person you identify who are involved in your care or payment for your care, or to notify or assist in notifying those individuals of your location, general condition or death. UCAR does not have to agree to your request, but if we do, we will abide by our agreement until either of us terminates the agreement.

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