Patient forms

Notice of Privacy Practices.

A summary of how AmpleHealth protects, uses, and discloses your health information — and your rights under HIPAA.

Summary

AmpleHealth is committed to protecting the privacy of your protected health information (PHI). This notice describes how medical information about you may be used and disclosed, and how you can access that information.

How we use your information. We may use and disclose your PHI for treatment, payment, and routine healthcare operations — for example, coordinating with specialists, billing your insurer, and improving the quality of care we provide.

Disclosures permitted by law. In limited circumstances we may disclose PHI without your authorization, such as for public health activities, when required by law, or to prevent a serious threat to health or safety.

Your rights. You have the right to inspect and request a copy of your records, request corrections, request restrictions on certain disclosures, request confidential communications, and receive an accounting of disclosures. You may also request a paper copy of this notice at any time.

Our responsibilities. We are required by law to maintain the privacy of your PHI, provide you with this notice, and abide by the terms of the notice currently in effect. If you believe your privacy rights have been violated, you may file a complaint with our office or with the U.S. Department of Health and Human Services. We will never retaliate against you for filing a complaint.

Acknowledgment
Signature

By submitting, you confirm the information above is accurate to the best of your knowledge.