Practice Management Alert

SAMPLE PRIVACYLETTER: INTRODUCTION AND TABLE OFCONTENTS (from article 6) NOTICE OFPRIVACYPRACTICES OF[ENTITY'S NAME] and other healthcare providers that are members of our system, including the following: THIS NOTICE DESCRIBES HOW MEDICALINFORMATION ABOUTYOU MAYBE USED AND DISCLOSED AND HOWYOU CAN GETACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Effective:__________________ If you have any questions or requests, please contact______________ at ________________. Table of Contents A. We have a legal duty to protect health information about you. B. We may use and disclose PHI about you in the following circumstances. 1. We may use and disclose PHI about you to provide healthcare treatment to you.

2. We may use and disclose PHI about you to obtain payment for services.

3. We may use and disclose your PHI for healthcare operations. 4. We may use and disclose PHI under other circumstances without your authorization.

5. You can object to certain uses and disclosures. 6. We may contact you to provide appointment reminders. 7. We may contact you with information about treatment, services, products, or healthcare providers. 8. We may contact you for fund-raising activities. C. You have several rights regarding PHI about you. 1. You have the right to request restrictions on uses and disclosures of PHI about you.

2. You have the right to request different ways we communicate to you. 3. You have the right to see and obtain and copy PHI about you. 4. You have the right to request amendment of PHI about you. 5. You have the right to a listing of disclosures we have made. 6. You have a right to a copy of this Notice. D. You may file a complaint about our privacy practices. E. Effective date of this notice. $ $ $