Notice of Privacy Practices for Nutrition Services

Effective Date: [INSERT DATE]

This notice describes how medical and nutrition information about you may be used and disclosed and how you can access this information. Please review it carefully.

Our Commitment to Your Privacy

Our nutrition practice is dedicated to maintaining the privacy of your individually identifiable health information (also called protected health information, or PHI). We are required by law to maintain the confidentiality of health information that identifies you and to provide you with this notice of our legal duties and privacy practices.

How We May Use and Disclose Your Health Information

For Treatment

• Share information with other healthcare providers involved in your care
• Consult with other nutrition professionals about your treatment plan
• Contact you about appointment reminders

For Payment

• Bill and collect payment from you, your insurance company, or other third parties
• Verify insurance coverage and benefits

For Healthcare Operations

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

Your Health Information Rights

You have the right to:

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

Changes to This Notice

We reserve the right to change this notice at any time. Any revised notice will be effective for medical information we already have about you as well as any information we receive in the future.

To File a Complaint

If you believe your privacy rights have been violated, you may file a complaint with:

• Our practice's Privacy Officer at [INSERT CONTACT]
• The Secretary of the Department of Health and Human Services

Contact Information

For further information about this notice, please contact:

[PRACTICE NAME] Attn: Privacy Officer [ADDRESS] [PHONE] [EMAIL]