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INDIAN RIVER COUNTY <br /> INDIVIDUAL RIGHTS FORM <br /> INDIVIDUAL REQUEST TO INSPECT HEALTH INFORMATION <br /> I request to review health information held about me in the Indian River County Employee <br /> Health Care Plan group health plan' s "designated record set" in accordance with the Health <br /> Insurance Portability and Accountability Act of 1996 (HIPAA) . A "designated record set" <br /> includes information such as medical records : billing records ; enrollment, payment, claims <br /> adjudication and health plan case or medical management record systems ; or records used to <br /> make decisions about individuals . <br /> I understand that the group health plan has 30 days to respond to this request, and that if <br /> someone else holds the information or it is off-site, the response time is 60 days . <br /> I request that the information be provided in the following format : (circle one) <br /> . Paper Electronic <br /> Optional : I agree that the group health plan may provide a summary of the health information <br /> instead of allowing me to review the information. <br /> I agree to pay any fees for copying or summarizing my health information. Fees will be <br /> reasonable and cost-based, and include only the cost of copying, postage , and preparation of a <br /> summary (if I agree to a summary) . <br /> I understand that this request does not apply to certain health information, including : ( 1 ) <br /> information that is not held in the designated record set; (2) psychotherapy notes ; (3 ) information <br /> compiled in reasonable anticipation of or for litigation; and (4) other information not subject to <br /> the right to access information under HIPAA. <br /> Signature : Date : <br />