Effective date: [Effective date]
Our pledge
Tier 1 TRT PC is committed to protecting your protected health information ("PHI") and complying with the Health Insurance Portability and Accountability Act ("HIPAA") and applicable Massachusetts laws.
How we may use and disclose your PHI
- Treatment: to provide, coordinate, and manage your care.
- Payment: to bill for services and obtain payment.
- Health care operations: for quality improvement, training, audits, and similar activities.
- As required or permitted by law: public health, abuse reporting, judicial orders, law enforcement under specific circumstances, and similar permitted disclosures.
Disclosures requiring your authorization
Most uses and disclosures of psychotherapy notes, marketing, and the sale of PHI require your written authorization. You may revoke an authorization in writing at any time.
Your rights
- Inspect and obtain a copy of your records
- Request an amendment to your records
- Request an accounting of certain disclosures
- Request restrictions on certain uses or disclosures
- Request confidential communications
- Receive a paper copy of this notice on request
- File a complaint with us or with the U.S. Department of Health and Human Services
Breach notification
If a breach of unsecured PHI occurs, we will notify you as required by HIPAA and Massachusetts law (M.G.L. c. 93H).
Changes to this notice
We may revise this notice and apply the revised notice to all PHI we maintain. We will post the current version on our website and provide it to active patients.
Contact
To exercise any of your rights or to file a complaint, contact our Privacy Officer at [privacy@northshore-placeholder.com]. You may also contact the Office for Civil Rights at the U.S. Department of Health and Human Services.