The following is a summary of the types of activities for which protected health information may be used and disclosed by ____________ clinic, as permitted by law:
• Treatment: _______ Clinic may access and disclose information about you for the purpose of providing you treatment and services.
• Payment: __________ Clinic may access and disclose information about you to bill for services and treatment you received.
• Health Care Operations: ________ Clinic may access and disclose information about you to carry out functions necessary to run the health services and to continually improve the quality and effectiveness of the health care and services it provides.
You have the right to do the following:
• Review and receive a copy of your health information
• Request that limits be put on the use or disclosure of your health information
• Request that communications about your health information be made in ways that further protect your privacy
• Request to have corrections made to your health information
• Receive a listing of where and when your health information was disclosed
Acknowledgement of