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Notice of Privacy Practices

This is a free form you may use as a template to establish a notice of your privacy practices involving your business. Edit and customize the form and provide in a printed format along with a PDF so that your staff may easily distribute to new clients of services. This free template can be used in conjunction with the Acknowledgement form to document confirmation that the policy has been read and accepted prior to the start of services.

Notice of Privacy Practices
[COMPANY NAME]

Last updated April 26, 2017

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.

[Company Name] has always been committed to protecting the privacy of your personal health inforamtion. Federal regulations provide an additional framework for maintaining the privacy of protected health informaiton while providing individual's with notice of the Agency's legal duties and privacy practices with respect to protected health information.

"Protected Health Information" is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

This Notice of Privacy Practice describes how [Company] may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information.

[Company] must provide all people it serves with written notice of its privacy practices no later than the date of first service delivery, or as soon as possible after emergency treatment. [Company] must obtain written acknowledgement that you have received this notice, or written documentation specifying reasons for not obtaining such acknowledgement.

We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notie at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, you may obtain the revised Notice of Privacy Practices by calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.

If you have any questions about this Notice please contact the Privacy Officer at [Company], at [Street Address], [City], [State], [Zip Code], [Phone Number].


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Attain a receipt of privacy practices notice to acknowledge acceptance of this policy.