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.
Effective date: [date]. AB Psychiatry Group, PLLC 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.
We may use and disclose your PHI to provide, coordinate, or manage your care — for example, sharing information with a pharmacy to fill a prescription, or with another provider involved in your care.
We may use and disclose your PHI to obtain payment for services — for example, providing a superbill or documentation you request to submit to your insurer.
We may use and disclose your PHI for operations such as quality improvement, training, and administrative functions necessary to run the practice.
You may revoke an authorization in writing at any time, except to the extent we have already relied on it.
As permitted or required by law, we may use or disclose PHI for: public health activities; reporting suspected abuse, neglect, or domestic violence; health oversight activities; judicial and administrative proceedings; law enforcement purposes; to avert a serious threat to health or safety; workers’ compensation; and to coroners, medical examiners, or funeral directors. We may also disclose the minimum necessary information as otherwise required by law.
If you believe your privacy rights have been violated, you may file a complaint with us 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 or ask questions about this Notice, contact our Privacy Officer: [name], info@abpsychgroup.com, [phone], [mailing address].
We reserve the right to change this Notice and to make the revised Notice effective for PHI we already have as well as information we receive in the future.