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Member Rights Request Form Size: 128Kb

This form is used to exercise your rights regarding your protected health information. Use this form:

  • To amend protected health information or records
  • To restrict our use or disclosure of protected health information for treatment, payment or health care operations or to persons involved in the your care or payment for that care
  • To request that we use alternative means or an alternative location when communicating about protected health information that we maintain
  • To request an accounting of disclosures of protected health information that we maintain
  • To inspect and/or obtain copies of your own protected health information
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