Your Notice of Privacy Practices, built as you answer

[Your practice legal name] [Practice street address] Phone: [Practice phone]

Effective date: July 29, 2026

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

“Medical information” in this notice includes your clinical and billing records: assessments, treatment plans, progress notes, and billing records.

This notice is written to 45 CFR § 164.520. The header statement above is the exact wording the rule requires at § 164.520(b)(1)(i); do not edit it. (Guidance note, not part of the document. Remove before posting.)

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get a copy of your records (§ 164.524). You can ask to see or get a copy of your records, on paper or electronically. We will provide a copy or a summary, usually within 30 days of your request. We may charge a reasonable, cost-based fee. You can also direct us in writing to send a copy to a person you designate.

Ask us to correct your records (§ 164.526). You can ask us to amend health information about you that you believe is incorrect or incomplete. We may say no, but we will tell you why in writing within 60 days, and you may add a written statement of disagreement to your record.

Request confidential communications (§ 164.522(b)). You can ask us to contact you in a specific way (for example, only by cell phone) or at a different address. We will accommodate all reasonable requests, and we will not ask you why.

Ask us to limit what we use or share (§ 164.522(a)). You can ask us not to use or share certain information for treatment, payment, or operations. We are not required to agree, and we may say no if it would affect your care. Exception we must honor: if you pay for an item or service in full, out of pocket, and ask us not to share that information with your health plan for payment or operations purposes, we must agree, unless the disclosure is required by law (§ 164.522(a)(1)(vi)).

Get a list of those with whom we have shared information (§ 164.528). You can ask for an accounting of the disclosures we have made of your health information in the six years before your request. This excludes certain disclosures, such as those for treatment, payment, and operations, and those you authorized. We will provide one accounting per year for free but may charge a reasonable, cost-based fee for more within 12 months.

Get a paper copy of this notice. You can ask for a paper copy at any time, even if you agreed to receive it electronically.

Choose someone to act for you. If someone is your personal representative (for example, a parent of a minor patient, or someone with health care power of attorney), that person can exercise your rights and make choices about your health information. We will confirm the person has this authority before we act (§ 164.502(g)).

File a complaint if you feel your rights are violated. You can complain to us using the contact information at the end of this notice, and you can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights, 200 Independence Avenue S.W., Washington, D.C. 20201, by calling 1-877-696-6775, or online at www.hhs.gov/hipaa/filing-a-complaint/index.html. We will not retaliate against you for filing a complaint (§ 164.530(g)).