Notice of Privacy Practices

This Notice describes how medical information about you may be used and disclosed, how you can obtain access to that information, and the privacy rights available to you. Please review it carefully.

Covered entity responsible for this Notice: [FINAL COVERED ENTITY NAME]

You may have the right, subject to applicable law, to:

• obtain an electronic or paper copy of your medical record;
• request correction of your medical record;
• request confidential communications;
• request restrictions on certain uses or disclosures;
• receive information regarding certain disclosures of your health information;
• obtain a copy of this Notice;
• authorize another person to act on your behalf;
• and file a complaint if you believe your privacy rights have been violated.

In certain circumstances, you may have choices regarding how health information is shared, including communications involving family members, certain marketing activities, and other uses requiring authorization.

Medical information may be used and disclosed as permitted by law for purposes including:

• treatment;
• payment;
• healthcare operations;
• public health and safety;
• legal compliance;
• health oversight;
• workers' compensation where applicable;
• law-enforcement requests where legally authorized;
• and other purposes permitted or required by law.

Uses or disclosures requiring authorization will not occur without the authorization required by applicable law.

The healthcare organization responsible for your medical record is required to maintain the privacy and security of Protected Health Information as required by applicable law.

Patients will be notified following a breach of unsecured Protected Health Information when notification is legally required.

The applicable healthcare organization must follow the duties and privacy practices described in the currently effective Notice.

You may raise privacy concerns or file a complaint without retaliation.

You may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights: HHS OCR complaint information.