Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Effective [Effective Date]
Our duties
We are required by law to maintain the privacy of your protected health information, to give you this notice of our legal duties and privacy practices, to follow the terms of the notice currently in effect, and to notify you following a breach of your unsecured health information.
How we may use and disclose your information
Treatment: to provide and coordinate your care, including with other providers involved in it.
Payment: to bill and receive payment for services.
Health care operations: to run our practice, including quality assessment, training, and outcome measurement.
As required by law: including public health reporting, health oversight, legal proceedings, law enforcement where permitted, and to prevent a serious threat to health or safety.
Research: where permitted by law, with appropriate approval and safeguards, or with your authorization. Outcome data used for publication is de-identified.
Uses that require your written authorization
Marketing, sale of your information, and most other uses not described in this notice. You may revoke an authorization in writing at any time, except to the extent we have already acted on it.
Your rights
Access: to see or receive a copy of your health records.
Amendment: to ask us to correct information you believe is incorrect or incomplete.
Accounting of disclosures: to receive a list of certain disclosures we have made.
Restrictions: to ask us to limit certain uses or disclosures; we must agree to restrict disclosures to a health plan for services you paid for in full out of pocket.
Confidential communications: to ask us to contact you in a specific way or at a specific place.
Paper copy: to receive a paper copy of this notice at any time.
Changes to this notice
We may change this notice; changes apply to all information we hold. The current notice is posted on our website and available at our office.
Complaints
If you believe your privacy rights have been violated, you may file a complaint with us at [Privacy Officer], [Address], [Phone], [Email], or with the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you for filing a complaint.