Notice of Privacy Practices for Plastic Surgery Practice

[Practice Name] Plastic Surgery

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 obtain access to this information. Please review it carefully.

Protected Health Information (PHI)

We understand the importance of privacy and are committed to maintaining the confidentiality of your medical information. We create records of the care and services you receive to provide quality care and comply with legal requirements.

Use and Disclosure of Medical Information

We May Use Your PHI for:

• Treatment planning and coordination
• Payment processing and insurance verification
• Healthcare operations and quality assessment
• Pre- and post-operative photography (with specific consent)
• Appointment reminders and follow-up care

Special Circumstances for Disclosure:

• Public health activities
• Health oversight activities
• Law enforcement purposes
• Workers' compensation cases
• Legal proceedings

Your Rights Regarding Medical Information

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 amend this Notice of Privacy Practices at any time. We will post a copy of the current notice in our office and on our website.

Complaints

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

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 Name: _________________ Signature: ____________________ Date: ________________________