Healthcare Notice of Privacy

HEALTHCARE NOTICE OF PRIVACY PRACTICES

Facility Name:    Effective Date:

Purpose

This Notice describes how medical information about you may be used and disclosed and how you can obtain access to this information. The facility is required by federal privacy law to maintain the privacy of protected health information, to provide individuals with notice of its legal duties and privacy practices, and to abide by the terms of the notice currently in effect.

Uses and Disclosures of Protected Health Information

We use and disclose health information for treatment, payment, and healthcare operations without your written authorization when permitted by law. Examples include:

- Treatment: disclosure to other healthcare providers involved in your care.

- Payment: disclosure to insurers and billing agents to obtain payment for services rendered.

- Healthcare Operations: internal activities including quality assessment, audits, and staff training.

Patient Rights

Right to Inspect and Copy: You have the right to request access to your protected health information. To request access, submit a written request specifying the information and form of access. The facility may charge a reasonable fee for copies.

Right to Amend: You have the right to request amendment of your records if you believe they are incorrect or incomplete. Submit a written statement describing the requested amendment and the reasons supporting it.

Accounting of Disclosures: You have the right to receive an accounting of certain disclosures of your protected health information made by the facility for up to six years prior to the date of your request, except for disclosures made for treatment, payment and healthcare operations and other exceptions provided by law.

Right to Request Restrictions: You may request restrictions on certain uses and disclosures of your health information. The facility is not required to agree to requested restrictions but will comply with any agreed restrictions in writing, except where disclosure is required by law.

Confidential Communications: You may request that communications of protected health information be made by alternative means or at alternative locations. The facility will accommodate reasonable requests when feasible. Preferred method(s) of contact (select):

Authorization and Other Uses

Uses and disclosures other than those described in this Notice will be made only with your written authorization. You may revoke such an authorization in writing, except to the extent that the facility has already taken action in reliance on the authorization.

Complaints

If you believe your privacy rights have been violated, you may submit a complaint in writing to the facility's Privacy Officer. Filing a complaint will not affect the care or treatment provided to you.

Patient Information

Date of Birth:    Gender:

Insurance Information

Medical History (Optional)

Acknowledgment of Receipt

I acknowledge that I have been provided with the facility's Notice of Privacy Practices, which describes how my health information may be used and disclosed, and my rights with respect to that information. I understand that the facility reserves the right to change the terms of the Notice and that I may obtain a revised Notice upon request.

By signing below I certify that I have read or had explained to me the contents of this Notice and that I understand my rights as described herein. I understand that I may request a copy of this Notice.

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