Internal Medicine Practice Privacy Policy

Notice of Privacy Practices

Effective Date: [Date]

Introduction

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.

Our Commitment to Your Privacy

Our practice is dedicated to maintaining the privacy of your individually identifiable health information (also called protected health information, or PHI). In conducting our business, we will create records regarding you and the treatment and services we provide to you.

How We May Use and Disclose Your PHI

1. Treatment

   • Provide, coordinate, or manage your healthcare
   • Consult with other healthcare providers
   • Refer you to another provider

2. Payment

   • Bill and collect payment for services
   • Submit claims to insurance companies
   • Verify coverage with your health plan

3. Healthcare Operations

   • Quality assessment activities
   • Employee review activities
   • Training of medical students
   • Licensing and credentialing

Your Rights Regarding Your PHI

• Right to inspect and copy records
• Right to amend incorrect or incomplete information
• Right to receive an accounting of disclosures
• Right to request restrictions
• Right to confidential communications
• Right to receive notice of a breach

Changes to This Notice

We reserve the right to change this notice at any time and to make the revised notice effective for all PHI we maintain.

Contact Information

Privacy Officer: [Name] Phone: [Phone Number] Email: [Email Address]

Acknowledgment

I acknowledge that I have received a copy of this Notice of Privacy Practices.

Patient Signature

Date