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DRAFT make. A revocation must be made in writing and will not apply to any information disclosed before the City receives the revocation. . Request for an accounting of any disclosures of your protected health information made during the six years prior to receipt of your request. The accounting will not include any disclosures made for treatment, payment, or health care operations; any disclosures made directly to you; any disclosures made based upon your written authorization; any disclosures reported on a previous accounting; or any disclosures made before April 14, 2004. Generally, the accounting will be provided within 60 days of the date the City's Privacy Officer receives your written request. However, the Privacy Officer is allowed an additional 30 days if the Privacy Officer notifies you, in writing, of the reason for the delay and notifies you of the date by which you can expect the accounting. If you request more than one accounting within a 12 month period, the City may charge a reasonable fee for each additional accounting. . Request to inspect your PHI records maintained by the City. You may also request paper copies of this statement or your PHI records. If you request paper copies of your PHI records, the City may charge a reasonable fee for the copies. Request that the City amend your PHI that the City maintains if you find that there are errors in the record. All requests for amendments must be made in writing to the Privacy Officer and must include a reason for the amendment. Please be aware that the City can amend only the information that it creates. If your request is to amend information that the City did not create, the City will need a statement from the individual or organization that created the information explaining an error was made. The City has 60 days after it receives your request to respond. If the City is not able to respond, it is allowed one 30-day extension. If the City denies your request, either in part or in whole, the City will send you a written explanation for the denial. You may then submit a written statement disagreeing with the City's denial and have that statement included in any future disclosures. Request that the City communicate with you or other health plan participants by another means. For example if you want the City to communicate with you at a different address we can usually accommodate this request. The request must be made in writing. File a written complaint with the City Privacy Officer at: . . . City of Paris Health Plan A TTN : Gene Anderson P.O. Box 9037 Paris, TX 75460-9037 Or call: 903 784-9241 72 Rev. 10/27/04