Free Notice of Privacy Practices Template
Notice of Privacy Practices
[YOUR COMPANY NAME] is committed to protecting the privacy of your personal health information. This Notice of Privacy Practices describes how we may use and disclose your personal health information to carry out treatment, payment, or healthcare operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your personal health information.
Uses and Disclosures of Personal Health Information
We may use and disclose your personal health information for the following purposes:
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Treatment: We may use and disclose your personal health information to provide, coordinate, or manage your health care and related services. This includes sharing information with other healthcare providers regarding your treatment and coordinating and managing your healthcare with others.
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Payment: We may use and disclose your personal health information to obtain payment for the health care services we provide to you. This includes billing and collection activities, claims management, and other related functions.
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Health Care Operations: We may use and disclose your personal health information for our health care operations. These activities include, but are not limited to, quality assessment and improvement activities, employee review activities, training and education programs, and ensuring compliance with legal and regulatory requirements.
Other Permitted and Required Uses and Disclosures
We may also use and disclose your personal health information in the following instances:
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As required by law.
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For public health activities.
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To report abuse, neglect, or domestic violence.
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For health oversight activities.
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In response to legal proceedings.
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To law enforcement officials.
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To coroners, medical examiners, and funeral directors.
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For research purposes.
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To prevent a serious threat to health or safety.
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For specialized government functions.
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For workers’ compensation.
Your Rights
You have the following rights regarding your personal health information:
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The right to inspect and copy your personal health information.
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The right to request a restriction on the use or disclosure of your personal health information.
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The right to request to receive confidential communications.
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The right to request an amendment to your personal health information.
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The right to receive an accounting of certain disclosures.
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The right to obtain a paper copy of this notice.
Changes to This Notice
We reserve the right to change the terms of this Notice of Privacy Practices and to make the new notice provisions effective for all personal health information that we maintain. If we make material changes to our privacy practices, we will make the revised Notice available to you upon request and post it in our facility and on our website.
Complaints
If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. We will not retaliate against you for filing a complaint.
Contact Information
If you have any questions about this Notice of Privacy Practices, please contact our Privacy Officer at [YOUR COMPANY NUMBER].
