Notice of Privacy Practices for Urgent Care Centers

Effective Date: [INSERT DATE]

Introduction

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

At [URGENT CARE CENTER NAME], we are committed to protecting your health information. This Notice applies to all records of your care generated by our facility.

Your Health Information Rights

• Obtain a copy of your paper or electronic medical record
• Request corrections to your medical record
• Request confidential communication
• Ask us to limit the information we share
• Get a list of those with whom we've shared your information
• Receive a copy of this privacy notice
• Choose someone to act for you
• File a complaint if you believe your privacy rights have been violated

Our Uses and Disclosures

We may use and share your information to:

• Treat you
• Run our organization
• Bill for your services
• Help with public health and safety issues
• Comply with the law
• Work with medical examiners or funeral directors
• Address workers' compensation, law enforcement, and other government requests

Our Responsibilities

• Maintain the privacy and security of your protected health information
• Notify you promptly if a breach occurs
• Follow the duties and privacy practices described in this notice
• Obtain your written authorization for other uses and disclosures

Changes to This Notice

We reserve the right to change this notice and make the new notice apply to health information we already have, as well as any information we receive in the future.

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:

Signature: ___________________ Date: ___________________