Healthcare Privacy Practices Notice

HEALTHCARE PRIVACY PRACTICES NOTICE

Effective Date:

PATIENT INFORMATION

Date of Birth:    Gender:

EMERGENCY CONTACT

INSURANCE INFORMATION

Policy Number:    Group Number:

MEDICAL HISTORY SUMMARY (OPTIONAL)

NOTICE OF PRIVACY PRACTICES

This facility is required by law to maintain the privacy of your protected health information (PHI) and to provide you with this written Notice describing our legal duties and privacy practices. PHI includes information created or received by this facility that relates to your past, present, or future physical or mental health condition, the provision of health care, or payment for health care.

Uses and Disclosures: We may use and disclose PHI for treatment, payment and health care operations without your written authorization. Examples include communicating with other health care professionals involved in your care, submitting claims to payors, quality assessment, and care coordination. Uses beyond these purposes generally require your written authorization.

Permitted Uses Without Authorization: We may disclose PHI without your authorization where permitted by law, including public health reporting, reporting abuse or neglect, health oversight activities, judicial and administrative proceedings, law enforcement requests, and to avert a serious threat to health or safety. Such disclosures will be limited to the minimum necessary to accomplish the purpose.

Psychotherapy Notes, Marketing, and Sale of PHI: Psychotherapy notes require your authorization for most disclosures. We will not sell your PHI for remuneration without your written authorization. Uses of PHI for marketing purposes require your written authorization.

YOUR RIGHTS REGARDING PHI

Right to Inspect and Copy: You may request access to inspect or obtain a copy of your PHI maintained in a designated record set, subject to limited exceptions. We may charge a reasonable cost-based fee for copies.

Right to Amend: You may request amendment of your PHI if you believe it is incorrect or incomplete. We will review and may deny the request if records were not created by this organization or if the information is accurate and complete.

Right to an Accounting of Disclosures: You may request a list of disclosures of your PHI made by us in the six years prior to the request, subject to certain exceptions.

Right to Request Restrictions and Confidential Communications: You may request restrictions on uses and disclosures of PHI and request confidential communications by alternative means or at alternative locations. We are not required to agree to all requests but will comply with reasonable requests and any agreements made will be upheld.

Right to Revoke Authorization: You may revoke an authorization previously provided for disclosures of PHI, except where we have already taken action in reliance on that authorization.

COMPLAINTS AND CONTACT

If you believe your privacy rights have been violated, you may file a complaint with our Privacy Officer. Filing a complaint will not affect your access to care or treatment. For assistance, contact:

Phone:    Email:

AUTHORIZATION AND LIMITS

Other uses of PHI not described in this Notice will be made only with your written authorization. You may revoke such authorizations in writing except to the extent we have relied upon them. Authorization expiration (if applicable):

We are required to notify you following any breach of unsecured PHI in accordance with applicable law.

CHANGES TO THIS NOTICE

We reserve the right to change the terms of this Notice and to make the revised Notice effective for all PHI we maintain. If we revise the Notice, we will provide a copy of the updated Notice.

ACKNOWLEDGMENT OF RECEIPT

I acknowledge that I have received or been offered a copy of the Healthcare Privacy Practices Notice. My signature below confirms receipt of this Notice and does not constitute authorization for any specific disclosure beyond treatment, payment, and health care operations unless indicated elsewhere in writing.

I acknowledge receipt of this Notice

CONSENT FOR ROUTINE CONTACT (OPTIONAL)

We may contact you by phone, voicemail, mail, or email regarding appointments, billing, or treatment information. You may request that we use alternative means or locations for communications.

You may leave detailed voicemail messages regarding appointments

You may receive text messages for appointment reminders and patient communications

Sign Now