Notice of Privacy Practices for Family Medicine Practice

Effective Date: [INSERT 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 protected health information (PHI). We are required by law to maintain the confidentiality of your health information and provide you with this notice of our legal duties and privacy practices.

How We May Use and Disclose Your Health Information

Treatment

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

Payment

• Submitting claims to your insurance company
• Obtaining payment for services provided
• Collecting unpaid balances

Healthcare Operations

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

Your Health Information Rights

1. Right to Inspect and Copy
2. Right to Amend
3. Right to an Accounting of Disclosures
4. Right to Request Restrictions
5. Right to Request Confidential Communications
6. Right to a Paper Copy of This Notice

Changes to This Notice

We reserve the right to change this notice. We will post a copy of the current notice in our facility with the effective date.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services.

Contact Information

Practice Name: [INSERT PRACTICE NAME] Address: [INSERT ADDRESS] Phone: [INSERT PHONE] Privacy Officer: [INSERT NAME]

By signing below, I acknowledge that I have received a copy of this Notice of Privacy Practices.

Patient Name: ________________ Signature: ________________ Date: ________________