Effective date: [INSERT DATE]
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.
Keystone Natural Family Medicine is required by law to maintain the privacy of your protected health information (“PHI”), to provide you with this Notice of our legal duties and privacy practices, and to follow the terms of the Notice currently in effect. PHI is information that identifies you and relates to your past, present, or future health, care, or payment for care.
Treatment. We use and disclose your PHI to provide, coordinate, and manage your care, including sharing information with other providers, specialists, labs, and pharmacies involved in your treatment.
Payment. We may use and disclose your PHI to obtain payment for services, including for membership billing, processing payments, and coordinating with health share or insurance entities at your request.
Health care operations. We may use and disclose your PHI for operations such as quality improvement, staff training, care coordination, and administrative functions necessary to run the practice.
Appointment reminders and care communications. We may contact you to provide appointment reminders, lab results, or information about treatment options and health-related services that may be of interest to you.
We may use or disclose your PHI without your authorization in certain situations, including: as required by law; for public health activities; to report suspected abuse, neglect, or domestic violence; for health oversight activities; in connection with judicial or administrative proceedings; for law enforcement purposes; to coroners, medical examiners, and funeral directors; for organ donation; for research under approved conditions; to avert a serious threat to health or safety; for specialized government functions; and for workers’ compensation as authorized by law.
Most uses and disclosures of psychotherapy notes, uses and disclosures for marketing purposes, and disclosures that constitute a sale of PHI require your written authorization. Other uses and disclosures not described in this Notice will be made only with your written authorization, which you may revoke at any time in writing.
You have the right to: inspect and request a copy of your PHI; request that we amend your PHI; receive an accounting of certain disclosures; request restrictions on certain uses and disclosures; request to receive confidential communications by alternative means or at an alternative location; receive a paper copy of this Notice; and be notified following a breach of unsecured PHI. To exercise these rights, contact our Privacy Officer using the information below.
We are required to maintain the privacy of your PHI, provide you with this Notice, abide by the terms of the Notice currently in effect, notify you if we are unable to agree to a requested restriction, and accommodate reasonable requests for confidential communications.
We reserve the right to change this Notice and to make the revised Notice effective for PHI we already have as well as any information we receive in the future. The current Notice will be posted in our offices and on our website, with its effective date shown above.
If you believe your privacy rights have been violated, you may file a complaint with our Privacy Officer or with the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you for filing a complaint.
To exercise your rights, ask questions, or file a complaint, contact our Privacy Officer at [INSERT PRIVACY OFFICER NAME], [INSERT EMAIL], [INSERT PHONE], [INSERT MAILING ADDRESS].
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