Notice of Privacy Practices for Gastroenterology Practice

[Practice Name] Gastroenterology

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 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 Information

Treatment

• Consulting with other healthcare providers about your care
• Scheduling procedures and follow-up appointments
• Sending prescriptions to your pharmacy
• Coordinating with other specialists involved in your digestive health care

Payment

• Verifying insurance coverage
• Billing and collections
• Submitting claims for procedures and visits

Healthcare Operations

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

Your Privacy Rights

You have the right to:

1. Request restrictions on certain uses of your health information
2. Receive confidential communications
3. Inspect and copy your health records
4. Request amendments to your health information
5. Receive an accounting of disclosures
6. Obtain a paper copy of this notice

Special Protections

Special privacy protections apply to:

• HIV-related information
• Alcohol and substance abuse treatment information
• Mental health treatment information
• Genetic testing information

Changes to This Notice

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

Contact Information

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

Acknowledgment

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

Patient Signature

Date