Physical Therapy Practice Notice of Privacy Practices

[Practice Name] Physical Therapy

Effective Date: [Date]

Our Commitment to Your Privacy

Your health information privacy is important to us. This notice describes how your medical information may be used and disclosed and how you can access this information.

Protected Health Information (PHI)

We create and maintain records of your health information, treatments, and payments. This protected health information (PHI) includes:

• Health records
• Treatment plans
• Progress notes
• Payment information
• Insurance details

How We May Use and Disclose Your PHI

Treatment

• Coordinating care with other healthcare providers
• Sharing information with referring physicians
• Documenting your therapy progress

Payment

• Billing insurance companies
• Verifying coverage
• Processing payments

Healthcare Operations

• Quality assessment
• Staff training
• Business planning

Your Rights Regarding PHI

You have the right to:

1. Request restrictions on PHI use
2. Receive confidential communications
3. Inspect and copy your records
4. Request amendments to your records
5. Receive an accounting of disclosures
6. Obtain a paper copy of this notice

Our Responsibilities

We are required to:

• Maintain PHI privacy
• Provide this notice of our duties and practices
• Follow the terms of our current notice
• Notify you of breaches of unsecured PHI

Contact Information

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

Acknowledgment

I acknowledge receipt of this Notice of Privacy Practices:

Signature: _________________ Date: _____________________