Effective date: [Effective date to be confirmed]
This notice describes how medical information about you may be used and disclosed by Evolve Wellness & Medical Collective and how you can get access to this information. Please review it carefully.
How medical information may be used and disclosed
[Practice-reviewed overview of permitted uses and disclosures]
Treatment
[Practice-reviewed language on uses for treatment]
Payment
[Practice-reviewed language on uses for payment]
Healthcare operations
[Practice-reviewed language on healthcare operations]
Your rights
[Practice-reviewed summary of patient rights]
Access to your records
[How to request access to or copies of records, including any fees]
Requesting amendments
[How to request an amendment to your records]
Requesting restrictions
[How to request restrictions on uses and disclosures]
Confidential communications
[How to request communication by alternative means or locations]
Accounting of disclosures
[How to request an accounting of disclosures]
Copies of this notice
[How to obtain a paper copy of this notice]
Complaints
[How to file a complaint with the practice and with the U.S. Department of Health and Human Services; statement of non-retaliation]
Our responsibilities
[Practice-reviewed statement of the practice's legal responsibilities]
Privacy contact information
[Privacy contact name or title]
[Mailing address]
[Phone number]
[Email address]
Effective date
[Effective date of this notice]
Questions? Contact the practice.