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.

OUR COMMITMENT TO YOUR PRIVACY:
[Healthcare Facility Name] is committed to maintaining the privacy of your protected health information (PHI) and follows strict security standards to protect your health information.
USES AND DISCLOSURES OF YOUR PHI:
We may use and disclose your PHI for treatment, payment, and healthcare operations without your written authorization. We may also use and disclose your PHI for other purposes with your written authorization.
YOUR RIGHTS REGARDING YOUR PHI:
- Right to Access: You have the right to access your medical records and obtain copies.
- Right to Request Amendments: You can request amendments to your medical records if you believe they are inaccurate or incomplete.
- Right to Request Restrictions: You can request restrictions on the use and disclosure of your PHI.
- Right to an Accounting of Disclosures: You can request a list of certain disclosures of your PHI that we have made.
- Right to Request Confidential Communications: You can request that we communicate with you in a specific way to protect your privacy.
OUR LEGAL DUTIES:
We are required by law to maintain the privacy of your PHI and provide you with this NPP. We are also required to notify you if there is a breach of your unsecured PHI.
QUESTIONS AND COMPLAINTS:
If you have questions about this NPP or our privacy practices, or if you believe your privacy rights have been violated, you can contact our Privacy Officer at [Contact Information]. You also have the right to file a complaint with the U.S. Department of Health and Human Services.
CHANGES TO THIS NOTICE:
We reserve the right to change the terms of this NPP and make the new provisions effective for all PHI that we maintain. Revised notices will be posted in our facility and on our website.
AUTHORIZATION FOR OTHER USES AND DISCLOSURES:
For uses and disclosures not covered by this NPP, we will obtain your written authorization. You may revoke such authorization at any time.

By signing the acknowledgment form, you confirm that you have received and understood this Notice of Privacy Practices.

Psychiatric Intake Form