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INDIAN RIVER COUNTY <br /> INDIVIDUAL RIGHTS FORMS <br /> GROUP HEALTH PLAN ' S RESPONSE TO AMENDMENT OR CORRECTION <br /> REQUEST <br /> Grant <br /> Your request to amend or correct your health information has been granted . The Plan will make <br /> an appropriate amendment to the designated record set. <br /> You must provide the Plan with the names and addresses of any persons to which <br /> you wish to <br /> these <br /> provide the amended information. The Plan then will make reasonable efforts inform <br /> individuals — and persons that the Plan knows may have relied or could rely on the information — <br /> of the amendment within a reasonable time . <br /> Need for Extension of Time <br /> The group health plan received your request to amend you re health information <br /> end health <br /> The group health plan has evaluatedy q o <br /> information. A delay in action is necessary for the following reason: <br /> The group health plan will respond to your request within 60 days of your request. <br /> Denial of Access <br /> The group health plan received your request to amend health information on. Your request is <br /> denied for the following reason: <br /> Statement of Disagreement <br /> You have the right to file a written statement disagreeing with denial of amendment. The <br /> statement of disagreement must be limited to two single-sided 84 /2 x 11 pages . The statement <br /> of disagreement should be filed within 60 days of this notice with the Health Benefits has the <br /> Administrator, Ann Rankin, Address 1840 25th Street, Vero Beach, F132960 . Th you will <br /> right to prepare a rebuttal statement to your statement of disagreement. If it does so , y <br /> receive a copy . <br /> If you do not submit a statement of disagreement, you may request that the Plan provide your <br /> request for amendment and this denial of amendment with any future disclosures of protected <br /> health information that is the subject of this request. <br /> You may file a complaint regarding this decision f you file a complaint with the group heallth plan, <br /> Department of Health and Human Sern y <br /> please file it in writing with the following person: Health Benefits Administrator, Ann Rankin. <br />