Page 6 – HIPAA Privacy Policy (Sign here) ---

 

HIPAA PRIVACY POLICY (Paper-based, Offline)

 

Notice of Privacy Practices for Protected Health Information (PHI)

 

This practice is required by law to maintain the privacy of your
health information. This notice describes how medical information
about you may be used and disclosed.

 

1.     Information collected: Name, date of birth, phone, address,
health condition, treatment records, intake forms, and SOAP notes.

2.     Storage: All records are kept as physical paper documents only.
No photos, no cloud, no internet connection. Stored securely in the
practitioner’s home.

3.     Retention: Records are retained for 7 years as required by
California law (Business and Professions Code section 4938).

4.     Use and disclosure:

•    Use only for treatment, appointment coordination, and necessary
communication.

•    Never shared, sold, or disclosed to any third party unless
required by law (e.g., court subpoena) or to prevent serious threat to
health/safety.

5.     Your rights:

•    You have the right to request access to or correction of your
paper records.

•     You have the right to receive an accounting of disclosure (if any).

•     To exercise these rights, contact the practitioner directly.

6.      Complaints: If you believe your privacy rights have been
violated, you may file a complaint with the practitioner or with the
U.S. Department of Health and Human Services.

I have read and agree to this Privacy Policy.

Patient signature: _____________________

Date: _____________________