Notice of Privacy Practices
Effective Date: [DATE]
Our Commitment to Your Privacy
At [Urgent Care Name], we are committed to protecting your medical information. This Notice describes how we may use and disclose your protected health information (PHI) to provide treatment, obtain payment, and conduct healthcare operations.
Your Health Information Rights
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Right to Inspect and Copy: You have the right to view and obtain copies of your health information
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Right to Amend: You can request corrections to your health information
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Right to an Accounting of Disclosures: You can request a list of when we've shared your information
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Right to Request Restrictions: You can ask us to limit the information we share
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Right to Confidential Communications: You can request communications in a specific way
How We May Use and Disclose Your Information
Treatment
- Sharing information with other healthcare providers involved in your care
- Coordinating services with specialists or laboratories
Payment
- Billing and collection activities
- Insurance verification and claims processing
Healthcare Operations
- Quality assessment activities
- Staff training and evaluation
- Business planning and management
Additional Permitted Uses
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Public Health Activities: Disease prevention, injury prevention, and public health surveillance
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Legal Requirements: Court orders, subpoenas, or other legal obligations
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Law Enforcement: When required by federal, state, or local law
Our Responsibilities
- Maintain privacy of your health information
- Provide notice of our legal duties and privacy practices
- Abide by the terms of this notice
- Notify you of breaches of unsecured PHI
Contact Information
Privacy Officer: [NAME]
Phone: [PHONE]
Email: [EMAIL]
Acknowledgment
I acknowledge receipt of this Notice of Privacy Practices:
Signature: _________________
Date: _____________________