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INDIAN RIVER COUNTY <br /> INDIVIDUAL RIGHTS FORMS <br /> GROUP HEALTH PLAN' S RESPONSE TO INSPECTION REQUEST <br /> Grant <br /> Your request to access your health information has been granted. Access will be provided by <br /> Need for Extension of Time <br /> The group health plan received your request to access health information on The <br /> group health plan has evaluated your request to access health information. A delay in providing <br /> the information is necessary for the following reason: <br /> The group health plan will respond to your request within 60 days from the date of your request. <br /> Denial of Access <br /> The group health plan received your request to access health information and was denied for the <br /> following reason: <br /> You may file a complaint regarding this decision with the group health plan or the U. S . <br /> Department of Health and Human Services . If you file a complaint with the group health plan, <br /> please file. it in writing with the following person: Benefits/Payroll Administrator, Ann Rankin, <br /> Fax 772 . 770 . 5004, Address 1840 25th Street, Vero Beach, Fl, 32960 . <br /> In certain cases you are entitled to appeal the denial of access. You are entitled to an appeal if <br /> access was denied because in the opinion of a licensed health care professional, granting access <br /> is likely to endanger the life or physical safety of you or another person. If you appeal, your <br /> appeal will be reviewed by a licensed health care professional designated by the plan that did not <br /> participate in the original decision. The appeal and notice of the appeal decision will be <br /> conducted promptly. <br /> Signature of Plan Representative Date <br />