Speech Therapy Practice Notice of Privacy Practices

[Practice Name] Speech Therapy Services

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 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 Information

For Treatment

• Share information with other healthcare providers involved in your care
• Coordinate services with other speech therapists
• Consult with medical professionals about your therapy plan

For Payment

• Submit claims to your insurance company
• Verify insurance coverage and benefits
• Collect payments from you, your insurance company, or other third parties

For Healthcare Operations

• Quality assessment activities
• Employee review activities
• Training speech therapy students
• Licensing and credentialing

Your Rights Regarding Your Health 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 change this notice. We will post a copy of the current notice in our facility with the effective date.

Complaints

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

Contact Information

Practice Name: [Name] Address: [Address] Phone: [Phone] Email: [Email]

Acknowledgment of Receipt

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

Patient Name: _________________ Signature: ____________________ Date: ________________________