Notice of Privacy Practices for Occupational Therapy Services

[Practice Name] Occupational Therapy Services

Effective Date: [Date]

Our Commitment to Your Privacy

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

Protected Health Information (PHI)

We understand that your health information is personal. We create and maintain records of your health information and treatment to provide quality care and comply with legal requirements. This information includes:

• Assessment results and observations
• Treatment plans and progress notes
• Medical history and diagnoses
• Insurance and billing information

How We May Use and Disclose Your Information

Treatment

• Share information with other healthcare providers involved in your care
• Coordinate services with other therapy providers
• Communicate with your referring physician

Payment

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

Healthcare Operations

• Quality assessment and improvement activities
• Employee review and training
• Compliance and licensing activities

Your Rights Regarding Your Health Information

1. Right to Inspect and Copy

   • You may request to view or obtain copies of your health records
   • We may charge a reasonable fee for copies

2. Right to Amend

   • You may request amendments to your health information
   • We may deny the request with written explanation

3. Right to an Accounting of Disclosures

   • You may request a list of disclosures we have made of your health information

4. Right to Request Restrictions

   • You may request limitations on how we use your health information

Changes to This Notice

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

Contact Information

If you have questions about this notice, please contact: [Practice Privacy Officer] Phone: [Phone Number] Email: [Email Address]

Acknowledgment

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

Patient/Guardian Signature

Date