THE QUALITY CARE YOU DESERVE

Our experienced primary care professionals are dedicated to your complete well-being

CIMCare Patient Individual Rights Forms

The following is a brief description of the various individual rights and the appropriate form to invoke one of these rights.

Notice of Privacy Practices

This document describes how CIMCare uses and discloses your personal, health and financial information. The document also outlines the various privacy rights available to patients. This form was last updated in August 2015.

English   |   Spanish

Request for Accounting of Disclosures

This form requests a list of disclosures CIMCare made of a member's protected health information. Disclosures made for payment and health plan operations are excluded from this process. The form was last updated in August 2015.

English   |   Spanish

Request Amendment to your Protected Health Information

This form requests a correction to CIMCare-created protected health information that a member feels is inaccurate or incomplete. This form was last updated August 2015.

English   |   Spanish

Request to Access Protected Health Information

This form requests an inspection or copy of CIMCare-maintained protected health information about a member. This form was last updated on August 2015.

English   |   Spanish

Request for Restriction of Protected Health Information

This form requests limitation or restriction of disclosures of a member's protected health information to others such as a family member, friend, spouse, doctor, or any other party. This form was last updated in August 2015.

English   |   Spanish

Request for Termination of Restriction

This form withdraws a previously requested restriction of a member's protected health information. The form was last updated in August 2015.

English   |   Spanish

Request for Alternate Communications

This form requests that CIMCare communicate with a member about protected health information in a different way during life-threatening situations. Examples of alternate means could include telephone, mail, e-mail, or different address. The form was last updated in August 2015.

English   |   Spanish

HIPAA Privacy Complaint Form

This form documents an issue or concern if a member believes his or her privacy rights may have been violated. This form was last updated in August 2015.

English   |   Spanish

Our Medical Center

Our newly renovated medical center spans over 2,000 square feet, has eight patient exam rooms and boasts a comfortable and spacious patient waiting area.

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