Effective Date

[Insert Date]

Last Updated

[Insert Date]

Introduction

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

How We May Use and Disclose Your PHI

We may use or disclose your PHI without your authorization for treatment, payment, healthcare operations, as required by law, public health and safety, health oversight activities, law enforcement, and workers’ compensation purposes.

Uses and Disclosures That Require Authorization

We will not use or disclose your PHI for marketing, sale of information, or psychotherapy notes without your written authorization. You may revoke authorization at any time.

Your Rights Regarding PHI

You have the right to inspect and copy records, request amendments, request restrictions, request confidential communications, receive an accounting of disclosures, and obtain a paper copy of this notice.

Our Duties