This form is used to exercise your rights regarding your protected health information. Use this form:

• To amend protected health information or records
• To restrict our use or disclosure of protected health information for treatment, payment or health care operations or to persons involved in the your care or payment for that care
• To request that we use alternative means or an alternative location when communicating about protected health information that we maintain
• To request an accounting of disclosures of protected health information that we maintain
• To inspect and/or obtain copies of your own protected health information