HIPAA Notice of Privacy Practices
© 2003 Domestic Violence Intervention Services, Inc.
All Rights Reserved
[This form does not constitute legal advice and is for educational purposes only. This form is based on current federal law and subject to change based on changes in federal law or subsequent interpretative guidance. This form is based on federal law and must be modified to reflect state law where that state law is more stringent than the federal law or other state law exceptions apply.
This notice describes how Personal Health and Medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.
We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices by accessing our website at www.dvis.org, by calling our main office and requesting that a revised copy be sent to you in the mail or by asking for one at the time of your next appointment.