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Notice of Privacy Practices

Last updated: May 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.

Our Duties

We are required by law to maintain the privacy of your protected health information (PHI), provide you with this notice of our legal duties and privacy practices, and follow the terms of this notice currently in effect.

How We May Use and Disclose Your PHI

Treatment: We may use and disclose your PHI to provide, coordinate, or manage your healthcare and related services. Payment: We may use and disclose your PHI to obtain payment for services provided to you. Healthcare Operations: We may use and disclose your PHI for our healthcare operations, including quality assessment, staff training, and business management.

Your Rights Regarding Your PHI

You have the right to: request restrictions on how we use or disclose your PHI; receive confidential communications; inspect and copy your PHI; request amendments to your PHI; receive an accounting of disclosures; and receive a paper copy of this notice.

Uses and Disclosures Requiring Your Authorization

We will obtain your written authorization before using or disclosing your PHI for purposes other than treatment, payment, or healthcare operations, except as permitted or required by law.

Required Disclosures

We are required to disclose your PHI when required by law, including to the Secretary of the Department of Health and Human Services for compliance investigations, and in certain public health and safety situations.

Changes to This Notice

We reserve the right to change this notice. We will post the revised notice on our website and make it available upon request. Changes will apply to PHI we already hold as well as PHI we receive in the future.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. We will not retaliate against you for filing a complaint. To file a complaint with our office, contact us through our website.

Effective Date

This Notice of Privacy Practices is effective as of May 2026.

[Practice Name]

123 Sample Street, Suite 200

Sample Town, NJ 08876

(555) 000-0100

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