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INDIAN RIVER COUNTY INDIVIDUAL RIGHTS FORMS GROUP HEALTH PLAN' S RESPONSE TO AMENDMENT OR CORRECTION REQUEST Grant Your request to amend or correct your health information has been granted. The Plan will make an appropriate amendment to the designated record set. You must provide the Plan with the names and addresses of any persons to which you wish to provide the amended information. The Plan then will make reasonable efforts to inform these individuals — and persons that the Plan knows may have relied or could rely on the information — of the amendment within a reasonable time. Need for Extension of Time The group health plan received your request to amend your health information on The group health plan has evaluated your request to amend health information. A delay in action is necessary for the following reason: The group health plan will respond to your request within 60 days of your request. Denial of Access The group health plan received your request to amend health information on. Your request is denied for the following reason: Statement of Disagreement You have the right to file a written statement disagreeing with denial of amendment. The statement of disagreement must be limited to two single- sided 81 /2 x 11 pages . The statement of disagreement should be filed within 60 days of this notice with the Benefits/Payroll Administrator, Ann Rankin, Address 1840 25th Street, Vero Beach, F132960. The Plan has the right to prepare a rebuttal statement to your statement of disagreement. If it does so, you will receive a copy. If you do not submit a statement of disagreement, you may request that the Plan provide your request for amendment and this denial of amendment with any future disclosures of protected health information that is the subject of this request. You may file a complaint regarding this decision with the group health plan or the U. S . Department of Health and Human Services . If you file a complaint with the group health plan, please file it in writing with the following person: Benefits/Payroll Administrator, Ann Rankin.