Orthopedic Practice Notice of Privacy Practices

[Practice Name] Orthopedics

Effective Date: [Date]

This notice describes how medical 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 orthopedic 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 Medical Information

For Treatment

• Sharing information with other healthcare providers involved in your care
• Coordinating with physical therapists and rehabilitation specialists
• Consulting with other orthopedic specialists about your condition

For Payment

• Submitting claims to your insurance company
• Verifying coverage for surgical procedures
• Collections activities when necessary

For Healthcare Operations

• Quality assessment activities
• Employee review activities
• Training medical students and residents
• Compliance and licensing activities

Your Health Information Rights

You have the right to:

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

Changes to This Notice

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

Contact Information

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

Acknowledgment

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

Patient Signature

Date