Notice of Privacy Practices Acknowledgment

# Notice of Privacy Practices Acknowledgment **Practice Name:** ___________ This document confirms that you have received, or been offered, a copy of the above Practice's Notice of Privacy Practices (NPP) as required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its implementing regulations at 45 C.F.R. § 164.520. The NPP describes how this Practice may use and disclose your protected health information (PHI), your rights regarding that information, and how you may exercise those rights. --- ## Summary of What Our Notice of Privacy Practices Covers The full Notice of Privacy Practices is available at ___________ (website or physical location). It includes, but is not limited to, the following topics: **Uses and Disclosures We May Make Without Your Authorization** - **Treatment.** We may use and share your PHI to coordinate or manage your healthcare and any related services with other providers involved in your care (e.g., specialists, hospitals, laboratories, pharmacies). - **Payment.** We may use and disclose your PHI to bill and collect payment for services rendered, including communications with your health insurance plan or other payer. - **Health Care Operations.** We may use and disclose your PHI for internal functions such as quality assessment and improvement activities, staff training, accreditation, legal services, and business management. - **Other Permitted Disclosures.** As permitted or required by law, we may disclose your PHI to public health authorities, law enforcement, courts, oversight agencies, or in response to a subpoena; to avert a serious threat to health or safety; for workers' compensation; and for other purposes described in the full NPP. **Uses and Disclosures That Require Your Written Authorization** Most uses and disclosures of psychotherapy notes, PHI for marketing purposes, and the sale of PHI require your written Authorization. You may revoke any Authorization you have given us in writing at any time. **Your Rights Regarding Your Protected Health Information** You have the right to: - Request restrictions on certain uses and disclosures of your PHI (we are not always required to agree, but we must agree to certain requests for restrictions involving self-pay services); - Request that we communicate with you by alternative means or at an alternative location; - Inspect and obtain a copy of your PHI maintained in our designated record set; - Request an amendment to your PHI; - Receive an accounting of certain disclosures we have made of your PHI; - Receive a paper copy of the Notice of Privacy Practices upon request, even if you have agreed to receive it electronically; - File a complaint with us or with the U.S. Department of Health and Human Services Office for Civil Rights if you believe your privacy rights have been violated (no retaliation will occur). **Effective Date of Current Notice:** ___________ **Contact for Questions or Complaints:** ___________, ___________, ___________, ___________, ___________ ---