Users Manual
205
AppendixAppendix
You Have the Right to Request a Restriction of Your Medical Information: You may ask us
not to use or disclose any part of your Medical Information for the purposes of treatment,
payment or healthcare operations. You may also request that any part of your Medical
Information not be disclosed to family members or friends who may be involved in your care
or for notication purposes as described in this HIPAA Privacy Notice. Your request must
state the specic restriction requested and to whom you want the restriction to apply. Except as
otherwise provided in this HIPAA Privacy Notice, we are not required to agree to a restriction
that you may request. We are required to agree to your request to restrict disclosure of your
Medical Information to a health plan if (i) the disclosure is to carry out payment or healthcare
operations and is not otherwise required by law; and (ii) your Medical Information pertains
solely to a healthcare item or service for which you or someone (other than the health plan)
on your behalf, has paid us in full. If we agree to the requested restriction, we may not use or
disclose your Medical Information in violation of that restriction unless it is needed to provide
emergency treatment. If you would like to request a restriction of the use of your Medical
Information, please download our Request Form at
https://www.myomnipod.com/images/upload/HIPAA_Privacy_Notice_Request_Form.pdf
and follow the directions included on that form. We will respond to your request in a
reasonable amount of time. Please contact our Privacy Ocer if you have questions about
requesting a restriction of the use of your Medical Information.
You Have the Right to Request to Receive Condential Communications from Us by
Alternative Means or at an Alternative Location: We will accommodate reasonable requests to
receive condential communications from us by alternate means or at an alternative location.
We may also limit this accommodation by asking you for information as to how payment will
be handled or specication of an alternative address or other method of contact. We will not
request an explanation from you as to the basis for the request. Please make this request in
writing to our Privacy Ocer.
You Have the Right to Receive an Accounting of Certain Disclosures We Have Made, if any, of
Your Medical Information: is right applies to disclosures for purposes other than treatment,
payment or healthcare operations as described in this HIPAA Privacy Notice. It excludes
disclosures we may have made to you, for a facility directory, to family members or friends
involved in your care, for notication purposes, for national security or intelligence purposes,
to correctional institutions or law enforcement ocials, or as part of a limited data set. You
have the right to receive specic information regarding these disclosures that occurred aer
April 14, 2003, or as otherwise provided for under applicable law. You may request a shorter
timeframe. e right to receive this information is subject to certain exceptions, restrictions
and limitations. If you would like to request an accounting of certain disclosure of your Medical
Information, please download our Request Form at
https://www.myomnipod.com/images/upload/HIPAA_Privacy_Notice_Request_Form.pdf
and follow the directions included on that form. We will respond to your request in a
reasonable amount of time. Please contact our Privacy Ocer if you have questions about
requesting an accounting of the disclosures of your Medical Information.
You Have e Right to Obtain a Copy of this HIPAA Privacy Notice: You have the right to
obtain a paper copy of this HIPAA Privacy Notice from us, upon request, even if you have
agreed to accept this notice electronically. If you would like to request a paper copy of this
HIPAA Privacy Notice, please download our Request form at
https://www.myomnipod.com/images/upload/HIPAA_Privacy_Notice_Request_Form.pdf
and follow the directions included on that form.