Free HIPAA reference template · v1.0 · Applies to covered entities
Adopting this document means committing to these HIPAA controls, the 45 CFR §164 requirements it helps satisfy, by area:
Template. The public notice a Covered Entity must give individuals describing how it uses and discloses PHI and their rights. Replace
[bracketed]items; have counsel confirm state-law additions. Post it, put it on your website, and provide it at first service with an acknowledgment. Satisfies 45 CFR § 164.520.
[Organization] (Effective [YYYY-MM-DD])
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.
We may use and disclose your protected health information (PHI) for treatment, payment, and health care operations without your authorization. We may also use or disclose it as required or permitted by law (for example, public health, legal requirements, or to avert a serious threat). Other uses and disclosures require your written authorization, which you may revoke.
You have the right to: inspect and get a copy of your PHI; request an amendment; request an accounting of certain disclosures; request restrictions and confidential communications; get a paper copy of this notice; and be notified of a breach of your unsecured PHI.
We are required by law to maintain the privacy of your PHI, provide this notice of our duties and practices, follow the terms of the notice in effect, and notify you of a breach.
You may complain to us or to the U.S. Department of Health and Human Services without retaliation. Contact our Privacy Official: [name / phone / email / address].
We reserve the right to change this notice; a revised notice applies to all PHI we maintain. v1.0.
See where your organization stands on the controls this template cites.
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