Notice of Privacy Practices

Effective Date: [DATE]

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.

Your Health Information Rights

You have the following rights regarding your PHI:

• Right to Inspect and Copy: You have the right to inspect and copy your health information
• Right to Amend: You have the right to request amendments to your health records
• Right to an Accounting of Disclosures: You have the right to receive an accounting of disclosures of your PHI
• Right to Request Restrictions: You have the right to request restrictions on certain uses of your PHI
• Right to Confidential Communications: You have the right to request confidential communication methods

How We May Use and Disclose Your PHI

Treatment

• Providing, coordinating, or managing your healthcare
• Consulting with other healthcare providers about your care

Payment

• Billing and collection activities
• Insurance verification and claims submission

Healthcare Operations

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

Special Circumstances

We may disclose your PHI without your authorization in the following situations:

1. Public health activities
2. Health oversight activities
3. Legal proceedings
4. Law enforcement
5. Research (with appropriate protocols)
6. Emergency situations

Changes to this Notice

We reserve the right to change this Notice at any time. We will post a copy of the current notice in our facility.

Contact Information

If you have questions about this Notice or would like to exercise your privacy rights, please contact our Privacy Officer at:

[Practice Name] Attn: Privacy Officer [Address] [Phone] [Email]