Notice of Privacy Practices — [Business Name]
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 Responsibilities
We are required by law to maintain the privacy of your protected health information (PHI), provide you with this notice of our legal duties and privacy practices, and follow the terms of the notice currently in effect.
How We Use and Disclose Your Health Information
We may use and disclose your PHI for the following purposes:
Treatment — To provide, coordinate, and manage your medical care. This includes sharing information with specialists, laboratories, and other providers involved in your care.
Payment — To obtain reimbursement for services provided, including billing your insurance carrier and communicating with third-party payers.
Healthcare Operations — To support the business activities of the practice, including quality improvement, staff training, compliance auditing, and business management.
With Your Authorization — For purposes not described above, we will obtain your written authorization before using or disclosing your PHI. You may revoke authorization at any time in writing.
Your Rights
- Access and obtain a copy of your health records
- Request corrections to your health information
- Request restrictions on certain uses and disclosures
- Request confidential communications (e.g., contact at an alternate address or phone number)
- Receive an accounting of disclosures made for purposes other than treatment, payment, or operations
- Receive a paper copy of this notice upon request
Breach Notification
We will notify you promptly if a breach of your unsecured PHI occurs, as required by federal law.
Contact
To exercise any of these rights or to file a complaint, contact:
Privacy Officer[Business Name]
[Street Address]
[City, State ZIP]
(000) 000-0000
info@example.com
You may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights.