Your Information. Your Rights. Our Responsibilities.

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.

Your Rights

You have the right to:

• Get a copy of your medical record (paper or electronic)

• Request a correction to your medical record

• Request confidential communications

• Ask us to limit the information we share

• Get a list of those with whom we’ve shared your information

• Get a copy of this privacy notice

• Choose someone to act for you

• File a complaint if you believe your privacy rights have been violated

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference, talk to us. Tell us what you want us to do, and we will follow your instructions.

You have both the right and the choice to tell us to:

• Share information with your family, close friends, or others involved in your care or payment for your care

We will never share your information for the following purposes without your written permission:

• Marketing purposes

• Sale of your information

• Most sharing of psychotherapy notes

If you are unable to communicate your preferences (for example, in an emergency), we may share your information if we believe it is in your best interest, or when needed to address a serious and imminent threat to health or safety.

Our Uses and Disclosures

How do we typically use or share your health information?

Treat You

We may use your health information and share it with other professionals who are treating you.

Example: A referring physician asks us about your nutritional status or dietary plan as part of coordinating your overall care.

Run Our Practice

We may use and share your health information to run our practice, improve your care, and contact you when necessary.

Example: We use information about you to manage your appointments, treatment plans, and follow-up services.

Bill for Our Services

We may use and share your health information to bill and collect payment from health plans or other entities.

Example: We provide information to your health insurance plan so it will pay for your services.

How else may we use or share your health information?

We are allowed or required to share your information in other ways — usually in ways that contribute to the public good. We must meet many conditions in the law before we can share your information for these purposes.

Help with Public Health and Safety

We may share health information about you in certain situations, such as:

• Preventing or controlling disease

• Reporting adverse reactions to medications or treatments

• Reporting suspected abuse, neglect, or domestic violence

• Preventing or reducing a serious threat to anyone’s health or safety

Research

We may use or share your information for health research conducted in compliance with applicable law and ethical standards.

Comply with the Law

We will share information about you if state or federal laws require it, including with the U.S. Department of Health and Human Services if it requests to verify our compliance with federal privacy law.

Law Enforcement and Government Requests

We may use or share health information about you:

• For law enforcement purposes or with a law enforcement official

• With health oversight agencies for activities authorized by law

• For special government functions such as military or national security matters

Respond to Lawsuits and Legal Actions

We may share health information about you in response to a court or administrative order, or in response to a subpoena.

Your Rights in Detail

When it comes to your health information, you have the following rights.

Get a Copy of Your Medical Record

You may ask to see or receive an electronic or paper copy of your medical record and other health information we have about you. We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask Us to Correct Your Medical Record

You may ask us to correct health information you believe is incorrect or incomplete. We may say “no” to your request, but we will tell you why in writing within 60 days.

Request Confidential Communications

You may ask us to contact you in a specific way (for example, by cell phone rather than home phone) or to send mail to a different address. We will say “yes” to all reasonable requests.

Ask Us to Limit What We Use or Share

You may ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request and may say “no” if it could affect your care. If we do agree, we may still share your information if you need emergency treatment.

If you pay for a service entirely out of pocket, you may ask us not to share that information with your health insurer for payment or operational purposes. We will honor this request unless a law requires us to share it.

Get a List of Those with Whom We’ve Shared Information

You may request an accounting of the times we’ve shared your health information during the six years prior to your request, including who we shared it with and why. We will include all disclosures except those related to treatment, payment, and health care operations, and certain other disclosures you authorized. We will provide one accounting per year at no charge; additional requests within 12 months may incur a reasonable, cost-based fee.

Get a Copy of This Notice

You may request a paper copy of this notice at any time, even if you previously agreed to receive it electronically. We will provide one promptly.

Choose Someone to Act for You

If someone has legal authority to act on your behalf — such as through a medical power of attorney or legal guardianship — that person may exercise your rights and make choices about your health information. We will verify this authority before taking any action.

File a Complaint

If you believe we have violated your privacy rights, you may contact us directly. You may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights:

• By mail: 200 Independence Avenue, S.W., Washington, D.C. 20201

• By phone: 1-877-696-6775

• Online: https://www.hhs.gov/hipaa/filing-a-complaint/index.html

We will not retaliate against you for filing a complaint.

Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.

• We will notify you promptly if a breach occurs that may have compromised the privacy or security of your information.

• We must follow the duties and privacy practices described in this notice and provide you with a copy upon request.

• We will not use or share your information other than as described in this notice unless you give us written permission. You may revoke that permission in writing at any time.

Changes to This Notice

We may change the terms of this notice at any time. Changes will apply to all health information we hold about you. The updated notice will be available upon request and on our website. For more information, visit: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html

Effective Date: 05/01/2026

This notice applies to the following organization: Hazelnut Health PLLC

Contact Person: privacy@hazelnut.health, 360-209-4050