HIPAA Notice of Privacy Practices



This Notice of Privacy Practices describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Our Pledge Regarding Your Health Information

We understand that medical information about you and your health is personal. We are committed to protecting your medical information. We create a record of the care and services you receive from us. We need this record to provide you with quality care and to comply with certain legal requirements.

This Notice Applies To

This Notice describes our practices and that of:

  • Any healthcare professional authorized to enter information into your medical record
  • All departments and units of our organization

Your Health Information Rights

You have the right to:

  1. Inspect and obtain a copy of your health record
  2. Amend your health record
  3. Obtain an accounting of disclosures of your health information
  4. Request restrictions on certain uses and disclosures of your information
  5. Request confidential communications
  6. Receive a paper copy of this Notice upon request

Our Responsibilities

We are required to:

  1. Maintain the privacy of your health information
  2. Provide you with this Notice of our legal duties and privacy practices
  3. Abide by the terms of this Notice
  4. Notify you if we are unable to agree to a requested restriction
  5. Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations

How We May Use and Disclose Your Health Information

We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

  • Treatment: We may use or disclose your health information to provide, coordinate, or manage your healthcare and any related services.
  • Payment: We may use and disclose your health information to obtain payment for services we provide to you.
  • Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations.

Other Uses and Disclosures

We may also use and disclose your health information in the following circumstances:

  • To comply with federal and state laws
  • To avert a serious threat to health or safety
  • For public health activities
  • For health oversight activities
  • For research purposes
  • For legal proceedings
  • For law enforcement purposes
  • For specialized government functions

Contact Information

If you have any questions about this Notice, please contact our Privacy Officer at [Contact Information].

Changes to This Notice

We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current Notice in the facility.