WMHS Notice of Privacy Practices 2026

Wombat Mental Health Services, LCSW PC NOTICE OF PRIVACY PRACTICES Effective Date: September 14, 2026 Supersedes the notice revised October 14, 2025 Your Information. Your Rights. Our Responsibilities. This notice describes how medical and behavioral health information about you may be used and disclosed, how you can obtain access to this information, and the responsibilities of Wombat Mental Health Services, LCSW PC (“WMHS” or “the Practice”) in protecting your information. Please review it carefully.

I. Your Rights Regarding Your Health Information

When it comes to your health information, you have certain rights. This section explains those rights and some of WMHS’s responsibilities.

1. Get an electronic or paper copy of your record. You may ask to inspect or receive an electronic or paper copy of your medical and behavioral health record and other health information maintained by WMHS. Psychotherapy notes and certain other information may not be included. When California law applies, records are generally made available for inspection within five working days and copies are generally provided within 15 days after a valid written request. Different timelines or limited exceptions may apply as permitted by law.
2. Ask us to correct your record. You may ask WMHS to correct health information that you believe is incorrect or incomplete. We may deny the request in some circumstances, but we will explain the reason in writing within the time required by law.
3. Request confidential communications. You may ask us to contact you in a particular way, such as by telephone, email, text, or mail, or at a different address. We will agree to reasonable requests.
4. Ask us to limit what we use or disclose. You may ask us not to use or disclose certain information for treatment, payment, or health care operations. We are not always required to agree. If you pay for a service in full out of pocket and ask us not to disclose information about that service to your health plan for payment or health care operations, we will honor the request unless disclosure is required by law.
5. Get a list of certain disclosures. You may request an accounting of certain disclosures of your health information made during the six years before your request. This accounting does not include every disclosure, such as many disclosures for treatment, payment, health care operations, or disclosures you authorized. One accounting in a 12month period is provided without charge; a reasonable cost-based fee may apply to additional requests.
6. Receive a copy of this notice. You may request a paper or electronic copy of this Notice at any time, even if you previously agreed to receive it electronically.
7. Choose someone to act for you. If a person has legal authority to act as your personal representative, such as a legal guardian or someone holding an applicable health care power of attorney, that person may exercise your privacy rights. WMHS may verify the person’s authority before acting.
8. File a complaint without retaliation. You may complain to WMHS or to the U.S. Department of Health and Human Services Office for Civil Rights if you believe your privacy rights have been violated. WMHS will not retaliate against you for filing a complaint.

II. How WMHS Typically Uses and Discloses Your Health Information

WMHS may use and disclose your protected health information without your written authorization for treatment, payment,

and health care operations, as permitted by law.

1. Treatment. We may use your health information and share it with clinicians and other health care professionals involved in your care. This may include consultation, supervision, care coordination, referrals, and communication with another treating provider.
2. Example: Your WMHS clinician may consult with an authorized supervisor or coordinate with another provider involved in your treatment.
3. Payment. We may use and disclose information needed to bill for services and receive payment. This may include sharing information with your health plan, Medi-Cal managed care plan, county behavioral health plan, billing service, or another responsible payer. Example: We may provide your health plan with information needed to process a claim or determine coverage.
4. Health care operations. We may use and disclose information to operate the Practice, improve services, evaluate quality, supervise clinicians, conduct compliance activities, schedule appointments, manage records, and perform other administrative functions.
   1. Example: WMHS may review clinical documentation to support quality of care, supervision, billing accuracy, or legal and regulatory compliance.
5. Business associates. WMHS may share information with organizations that perform services on our behalf, such as electronic health record, telehealth, billing, information technology, accounting, legal, or administrative services. When required, these organizations enter into written agreements requiring them to appropriately safeguard protected health information.
6. Appointment reminders and health-related communications. We may use your contact information to provide appointment reminders, communicate about treatment, describe treatment alternatives, or tell you about health-related services that may be relevant to your care. We will make reasonable efforts to follow your communication preferences.
7. Electronic systems and telehealth. WMHS may create, receive, store, or transmit protected health information through its electronic health record, telehealth platform, secure messaging systems, and other systems used to provide or coordinate care. Access is limited to workforce members and authorized service providers who need the information to perform their responsibilities.
8. Substance use disorder records. To the extent WMHS receives or maintains substance use disorder patient records that are protected by 42 CFR Part 2, those records will be used and disclosed only as permitted by applicable law. Information from Part 2 records may not be used or disclosed in a civil, criminal, administrative, or legislative investigation or proceeding against you without your written consent or a qualifying court order and subpoena, as required by law.

III. Uses and Disclosures That Require Your Written Authorization

WMHS will obtain your written authorization before using or disclosing your protected health information for purposes not described in this Notice, unless the use or disclosure is otherwise permitted or required by law.

1. Psychotherapy notes. To the extent WMHS creates or maintains “psychotherapy notes” as that term is specifically defined by HIPAA, most uses or disclosures of those notes require your written authorization. Authorization is not required for limited purposes permitted by law, including use by the clinician who created the notes for your treatment; certain supervised mental health training activities; defending WMHS or its workforce members in a legal proceeding brought by you; oversight by the U.S. Department of Health and Human Services; uses required by law; certain health oversight activities; use by a coroner or medical examiner; or uses needed to prevent or reduce a serious and imminent threat to health or safety.

2. WMHS Notice of Privacy Practices 2026

   CLIENT COPY

   Wombat Mental Health Services, LCSW PC NOTICE OF PRIVACY PRACTICES Effective Date: September 14, 2026 Supersedes the notice revised October 14, 2025 Your Information. Your Rights. Our Responsibilities. This notice describes how medical and behavioral health information about you may be used and disclosed, how you can obtain access to this information, and the responsibilities of Wombat Mental Health Services, LCSW PC (“WMHS” or “the Practice”) in protecting your information. Please review it carefully.

   I. Your Rights Regarding Your Health Information

   When it comes to your health information, you have certain rights. This section explains those rights and some of WMHS’s responsibilities.

   1. Get an electronic or paper copy of your record. You may ask to inspect or receive an electronic or paper copy of your medical and behavioral health record and other health information maintained by WMHS. Psychotherapy notes and certain other information may not be included. When California law applies, records are generally made available for inspection within five working days and copies are generally provided within 15 days after a valid written request. Different timelines or limited exceptions may apply as permitted by law.
   2. Ask us to correct your record. You may ask WMHS to correct health information that you believe is incorrect or incomplete. We may deny the request in some circumstances, but we will explain the reason in writing within the time required by law.
   3. Request confidential communications. You may ask us to contact you in a particular way, such as by telephone, email, text, or mail, or at a different address. We will agree to reasonable requests.
   4. Ask us to limit what we use or disclose. You may ask us not to use or disclose certain information for treatment, payment, or health care operations. We are not always required to agree. If you pay for a service in full out of pocket and ask us not to disclose information about that service to your health plan for payment or health care operations, we will honor the request unless disclosure is required by law.
   5. Get a list of certain disclosures. You may request an accounting of certain disclosures of your health information made during the six years before your request. This accounting does not include every disclosure, such as many disclosures for treatment, payment, health care operations, or disclosures you authorized. One accounting in a 12month period is provided without charge; a reasonable cost-based fee may apply to additional requests.
   6. Receive a copy of this notice. You may request a paper or electronic copy of this Notice at any time, even if you previously agreed to receive it electronically.
   7. Choose someone to act for you. If a person has legal authority to act as your personal representative, such as a legal guardian or someone holding an applicable health care power of attorney, that person may exercise your privacy rights. WMHS may verify the person’s authority before acting.
   8. File a complaint without retaliation. You may complain to WMHS or to the U.S. Department of Health and Human Services Office for Civil Rights if you believe your privacy rights have been violated. WMHS will not retaliate against you for filing a complaint.

   II. How WMHS Typically Uses and Discloses Your Health Information

   WMHS may use and disclose your protected health information without your written authorization for treatment, payment,

   and health care operations, as permitted by law.

   1. Treatment. We may use your health information and share it with clinicians and other health care professionals involved in your care. This may include consultation, supervision, care coordination, referrals, and communication with another treating provider.
   2. Example: Your WMHS clinician may consult with an authorized supervisor or coordinate with another provider involved in your treatment.
   3. Payment. We may use and disclose information needed to bill for services and receive payment. This may include sharing information with your health plan, Medi-Cal managed care plan, county behavioral health plan, billing service, or another responsible payer. Example: We may provide your health plan with information needed to process a claim or determine coverage.
   4. Health care operations. We may use and disclose information to operate the Practice, improve services, evaluate quality, supervise clinicians, conduct compliance activities, schedule appointments, manage records, and perform other administrative functions. Example: WMHS may review clinical documentation to support quality of care, supervision, billing accuracy, or legal and regulatory compliance.
   5. Business associates. WMHS may share information with organizations that perform services on our behalf, such as electronic health record, telehealth, billing, information technology, accounting, legal, or administrative services. When required, these organizations enter into written agreements requiring them to appropriately safeguard protected health information.
   6. Appointment reminders and health-related communications. We may use your contact information to provide appointment reminders, communicate about treatment, describe treatment alternatives, or tell you about health-related services that may be relevant to your care. We will make reasonable efforts to follow your communication preferences.
   7. Electronic systems and telehealth. WMHS may create, receive, store, or transmit protected health information through its electronic health record, telehealth platform, secure messaging systems, and other systems used to provide or coordinate care. Access is limited to workforce members and authorized service providers who need the information to perform their responsibilities.
   8. Substance use disorder records. To the extent WMHS receives or maintains substance use disorder patient records that are protected by 42 CFR Part 2, those records will be used and disclosed only as permitted by applicable law. Information from Part 2 records may not be used or disclosed in a civil, criminal, administrative, or legislative investigation or proceeding against you without your written consent or a qualifying court order and subpoena, as required by law.

   III. Uses and Disclosures That Require Your Written Authorization

   WMHS will obtain your written authorization before using or disclosing your protected health information for purposes not described in this Notice, unless the use or disclosure is otherwise permitted or required by law.

   1. Psychotherapy notes. To the extent WMHS creates or maintains “psychotherapy notes” as that term is specifically defined by HIPAA, most uses or disclosures of those notes require your written authorization. Authorization is not required for limited purposes permitted by law, including use by the clinician who created the notes for your treatment; certain supervised mental health training activities; defending WMHS or its workforce members in a legal proceeding brought by you; oversight by the U.S. Department of Health and Human Services; uses required by law; certain health oversight activities; use by a coroner or medical examiner; or uses needed to prevent or reduce a serious and imminent threat to health or safety.
   2. Notes. Psychotherapy notes are different from progress notes and other information maintained in your clinical record. Progress notes, diagnoses, treatment plans, symptoms, functional status, medications, test results, and summaries of treatment are generally part of the clinical record and are not considered psychotherapy notes under HIPAA.
   3. Marketing. WMHS will not use or disclose your protected health information for marketing purposes when HIPAA requires authorization unless you first provide written authorization.
   4. Sale of protected health information. WMHS does not sell protected health information. We will obtain written authorization before any disclosure that HIPAA defines as a sale of protected health information.
   5. Substance use disorder records. When information is protected by 42 CFR Part 2, additional written consent or other legal authority may be required before WMHS may use, disclose, or redisclose that information.
   6. Other uses and disclosures. Uses and disclosures not described in this Notice will be made only with your written authorization unless otherwise permitted or required by law.
   7. You may revoke an authorization in writing at any time. Revocation will not affect actions already taken in reliance on the authorization, and other limitations permitted by law may apply. WMHS will not condition treatment, payment, enrollment, or eligibility for benefits on your signing an authorization except in the limited circumstances permitted by law.

   IV. Uses and Disclosures That Do Not Require Your Authorization

   WMHS may use or disclose your protected health information without your written authorization when permitted or required by federal or California law. These situations may include:

   1. When required by law. We may disclose information when a federal, state, or local law requires us to do so, including disclosures to the U.S. Department of Health and Human Services to demonstrate compliance with federal privacy requirements.
   2. Public health and safety activities. We may disclose information for legally authorized public health activities, such as preventing or controlling disease, reporting certain adverse events, supporting product recalls, or preventing or reducing a serious and imminent threat to someone’s health or safety.
   3. Reports of abuse, neglect, or violence. We may disclose information when permitted or required to report suspected child abuse or neglect, elder or dependent-adult abuse, or other abuse, neglect, or violence. When applicable, we will follow legal requirements intended to protect the individual involved.
   4. Serious threats of physical violence. When a client communicates a serious threat of physical violence against a reasonably identifiable victim or victims, WMHS may take protective actions permitted or required by California law. These actions may include notifying the potential victim or victims and contacting law enforcement.
   5. Health oversight. We may disclose information to authorized health oversight agencies for activities such as audits, investigations, inspections, licensing, credentialing, and disciplinary proceedings.
   6. Judicial and administrative proceedings. We may disclose information in response to a valid court or administrative order or, when legally permitted, in response to a subpoena, discovery request, or other lawful process. Additional protections may apply to mental health and substance use disorder records.
   7. Law enforcement. We may disclose information to law enforcement officials in the limited circumstances permitted or required by law.
   8. Coroners, medical examiners, and funeral directors. We may disclose information to these individuals when legally authorized and necessary for them to perform their duties.
   9. Organ and tissue donation. We may disclose information to organizations involved in organ, eye, or tissue donation and transplantation when applicable and permitted by law.
   10. Research. We may use or disclose information for research when the research has received any review or approval required by law, when you have authorized the disclosure, or when the information has been appropriately deidentified.
   11. Workers’ compensation. We may disclose information as authorized by and necessary to comply with workers’ compensation or similar programs.
   12. Special government functions. We may disclose information for certain military, national security, protective-service, correctional, or other government functions when permitted or required by law.
   13. Disaster-relief activities. We may disclose limited information to an organization assisting with disaster relief when needed to coordinate care or notify people involved in your care, subject to your rights and applicable law. When WMHS maintains substance use disorder patient records protected by 42 CFR Part 2, those records receive additional protections. Information from Part 2 records may not be used or disclosed in a civil, criminal, administrative, or legislative investigation or proceeding against you without your written consent or a qualifying court order and subpoena, as required by law. WMHS will comply with any federal or California law that provides greater privacy protection than HIPAA.

   V. Your Choices About Sharing Information With Other People

   You have choices about whether and how WMHS shares information with family members, friends, partners, caregivers, or other people involved in your care or payment for your care.

   1. People involved in your care or payment. With your agreement, permission, or opportunity to object, WMHS may share information that is directly relevant to another person’s involvement in your care or payment for your care.
   2. Emergencies or incapacity. If you are unable to communicate your preferences, such as during a medical emergency or period of incapacity, WMHS may share limited relevant information when, using professional judgment, we believe the disclosure is in your best interest and is permitted by law.
   3. Disaster-relief situations. We may share limited information with an organization assisting with disaster relief when needed to coordinate care or notify people responsible for or involved in your care, unless you have objected or another legal restriction applies.
   4. Emergency contacts. Listing someone as an emergency contact does not automatically give that person unrestricted access to your health information or permission to participate in routine treatment decisions.
   5. Authorized contacts and releases of information. If you want WMHS to communicate regularly or share broader information with another person or organization, we may ask you to complete a separate Authorization for Release of Information or Authorized Contacts form. You may limit what information may be disclosed, the purpose of the disclosure, and how long the authorization remains effective. You may revoke the authorization in writing, subject to actions already taken in reliance on it. You may tell us your preferences, change your mind, or object to these disclosures at any time. WMHS will follow your instructions unless a disclosure is otherwise permitted or required by law, such as to address a serious and imminent threat to health or safety.

   VI. WMHS Responsibilities

   WMHS is required by law to:

   1. Maintain the privacy and security of your protected health information.
   2. Follow the duties and privacy practices described in the Notice that is currently in effect.
   3. Provide you with a copy of this Notice and make the current Notice available upon request and through the WMHS website.
   4. Use reasonable administrative, technical, and physical safeguards to protect your information and limit access to workforce members and authorized service providers who need the information to perform their responsibilities.
   5. Notify you promptly if a breach occurs that may have compromised the privacy or security of your protected health information, as required by law.
   6. Provide additional protections for substance use disorder patient records protected by 42 CFR Part 2 and for information protected by stricter federal or California privacy laws, when applicable.
   7. Refrain from using or disclosing your information for purposes other than those described in this Notice unless you provide written authorization or the use or disclosure is otherwise permitted or required by law.
   8. If you provide written authorization, you may revoke it in writing at any time. Your revocation will not affect actions already taken in reliance on the authorization.

    

   Changes to This Notice WMHS may change the terms of this Notice and apply the revised

   Notice to all protected health information maintained by the Practice, including information created or received before the change. When the Notice is materially revised, the updated version will be available upon request and posted on the WMHS website. The updated Notice will state its effective date.

   VII. Questions, Privacy Requests, and Complaints

   WMHS Privacy Contact the WMHS Privacy Officer if you:

   1. Have questions about this Notice or WMHS privacy practices.
   2. Want to exercise a privacy right described in this Notice.
   3. Want to request access to, a copy of, or a correction to your health information.
   4. Want to request confidential communications or restrictions on disclosures.
   5. Believe your privacy rights may have been violated. Wombat Mental Health Services, LCSW PC Attention: Privacy Officer 9431 Haven Avenue Rancho Cucamonga, CA 91730 Phone: (909) 529-8965 General questions: Info@WombatMHS.com Privacy complaints and concerns: Grievances@WombatMHS.com You may file a complaint directly with WMHS. Filing a complaint will not affect your eligibility for services or the care you receive. WMHS will not retaliate against you for submitting a question, concern, request, or complaint. U.S. Department of Health and Human Services You may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights: Online: https://www.hhs.gov/hipaa/filing-a-complaint/ Phone: 1-877-696-6775 Mail: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Washington, DC 20201 WMHS will not retaliate against you for filing a complaint with the Office for Civil Rights. You are not required to file a complaint with WMHS before contacting the Office for Civil Rights.

   VIII. Acknowledgment of Receipt

   This acknowledgment confirms that Wombat Mental Health Services, LCSW PC provided you with its Notice of Privacy Practices. Acknowledging receipt does not mean that you agree to any special use or disclosure of your health information. You may decline to sign this acknowledgment, and declining will not affect your eligibility for services or the care you receive. If you decline, WMHS will document its good-faith effort to provide you with the Notice. Please select one: (select one) I acknowledge that I received the WMHS Notice of Privacy Practices. I received the Notice but decline to sign the acknowledgment. I understand that this will not affect my services or care.

   Your selection above documents acknowledgment of receipt of the Notice. Your signature below confirms receipt only; it does not indicate consent to or agreement with any special use or disclosure of your health information. Name of person completing this acknowledgment *

   If completing this form for the patient, state your relationship and authority to act for them

   Signature acknowledging receipt of the Notice—not consent or agreement * Your signature below verifies that you made the selection above. If you selected acknowledgment, your signature acknowledges receipt of the Notice. If you selected decline, your signature documents your decision to decline the acknowledgment. In either case, your signature does not indicate consent to or agreement with any special use or disclosure of your health information. Psychotherapy notes are different from progress notes and other information maintained in your clinical record. Progress notes, diagnoses, treatment plans, symptoms, functional status, medications, test results, and summaries of treatment are generally part of the clinical record and are not considered psychotherapy notes under HIPAA.
3. Marketing. WMHS will not use or disclose your protected health information for marketing purposes when HIPAA requires authorization unless you first provide written authorization.
4. Sale of protected health information. WMHS does not sell protected health information. We will obtain written authorization before any disclosure that HIPAA defines as a sale of protected health information.
5. Substance use disorder records. When information is protected by 42 CFR Part 2, additional written consent or other legal authority may be required before WMHS may use, disclose, or redisclose that information.
6. Other uses and disclosures. Uses and disclosures not described in this Notice will be made only with your written authorization unless otherwise permitted or required by law.
7. You may revoke an authorization in writing at any time. Revocation will not affect actions already taken in reliance on the authorization, and other limitations permitted by law may apply. WMHS will not condition treatment, payment, enrollment, or eligibility for benefits on your signing an authorization except in the limited circumstances permitted by law.

IV. Uses and Disclosures That Do Not Require Your Authorization

WMHS may use or disclose your protected health information without your written authorization when permitted or required by federal or California law. These situations may include:

1. When required by law. We may disclose information when a federal, state, or local law requires us to do so, including disclosures to the U.S. Department of Health and Human Services to demonstrate compliance with federal privacy requirements.
2. Public health and safety activities. We may disclose information for legally authorized public health activities, such as preventing or controlling disease, reporting certain adverse events, supporting product recalls, or preventing or reducing a serious and imminent threat to someone’s health or safety.
3. Reports of abuse, neglect, or violence. We may disclose information when permitted or required to report suspected child abuse or neglect, elder or dependent-adult abuse, or other abuse, neglect, or violence. When applicable, we will follow legal requirements intended to protect the individual involved.
4. Serious threats of physical violence. When a client communicates a serious threat of physical violence against a reasonably identifiable victim or victims, WMHS may take protective actions permitted or required by California law. These actions may include notifying the potential victim or victims and contacting law enforcement.
5. Health oversight. We may disclose information to authorized health oversight agencies for activities such as audits, investigations, inspections, licensing, credentialing, and disciplinary proceedings.
6. Judicial and administrative proceedings. We may disclose information in response to a valid court or administrative order or, when legally permitted, in response to a subpoena, discovery request, or other lawful process. Additional protections may apply to mental health and substance use disorder records.
7. Law enforcement. We may disclose information to law enforcement officials in the limited circumstances permitted or required by law.
8. Coroners, medical examiners, and funeral directors. We may disclose information to these individuals when legally authorized and necessary for them to perform their duties.
9. Organ and tissue donation. We may disclose information to organizations involved in organ, eye, or tissue donation and transplantation when applicable and permitted by law.
10. Research. We may use or disclose information for research when the research has received any review or approval required by law, when you have authorized the disclosure, or when the information has been appropriately deidentified.
11. Workers’ compensation. We may disclose information as authorized by and necessary to comply with workers’ compensation or similar programs.
12. Special government functions. We may disclose information for certain military, national security, protective-service, correctional, or other government functions when permitted or required by law.
13. Disaster-relief activities. We may disclose limited information to an organization assisting with disaster relief when needed to coordinate care or notify people involved in your care, subject to your rights and applicable law. When WMHS maintains substance use disorder patient records protected by 42 CFR Part 2, those records receive additional protections. Information from Part 2 records may not be used or disclosed in a civil, criminal, administrative, or legislative investigation or proceeding against you without your written consent or a qualifying court order and subpoena, as required by law. WMHS will comply with any federal or California law that provides greater privacy protection than HIPAA.

V. Your Choices About Sharing Information With Other People

You have choices about whether and how WMHS shares information with family members, friends, partners, caregivers, or other people involved in your care or payment for your care.

1. People involved in your care or payment. With your agreement, permission, or opportunity to object, WMHS may share information that is directly relevant to another person’s involvement in your care or payment for your care.
2. Emergencies or incapacity. If you are unable to communicate your preferences, such as during a medical emergency or period of incapacity, WMHS may share limited relevant information when, using professional judgment, we believe the disclosure is in your best interest and is permitted by law.
3. Disaster-relief situations. We may share limited information with an organization assisting with disaster relief when needed to coordinate care or notify people responsible for or involved in your care, unless you have objected or another legal restriction applies.
4. Emergency contacts. Listing someone as an emergency contact does not automatically give that person unrestricted access to your health information or permission to participate in routine treatment decisions.
5. Authorized contacts and releases of information. If you want WMHS to communicate regularly or share broader information with another person or organization, we may ask you to complete a separate Authorization for Release of Information or Authorized Contacts form. You may limit what information may be disclosed, the purpose of the disclosure, and how long the authorization remains effective. You may revoke the authorization in writing, subject to actions already taken in reliance on it. You may tell us your preferences, change your mind, or object to these disclosures at any time. WMHS will follow your instructions unless a disclosure is otherwise permitted or required by law, such as to address a serious and imminent threat to health or safety.

VI. WMHS Responsibilities

WMHS is required by law to:

1. Maintain the privacy and security of your protected health information.
2. Follow the duties and privacy practices described in the Notice that is currently in effect.
3. Provide you with a copy of this Notice and make the current Notice available upon request and through the WMHS website.
4. Use reasonable administrative, technical, and physical safeguards to protect your information and limit access to workforce members and authorized service providers who need the information to perform their responsibilities.
5. Notify you promptly if a breach occurs that may have compromised the privacy or security of your protected health information, as required by law.
6. Provide additional protections for substance use disorder patient records protected by 42 CFR Part 2 and for information protected by stricter federal or California privacy laws, when applicable.
7. Refrain from using or disclosing your information for purposes other than those described in this Notice unless you provide written authorization or the use or disclosure is otherwise permitted or required by law.
8. If you provide written authorization, you may revoke it in writing at any time. Your revocation will not affect actions already taken in reliance on the authorization.

Changes to This Notice WMHS may change the terms of this Notice and apply the revised

Notice to all protected health information maintained by the Practice, including information created or received before the change. When the Notice is materially revised, the updated version will be available upon request and posted on the WMHS website. The updated Notice will state its effective date.

VII. Questions, Privacy Requests, and Complaints

WMHS Privacy Contact the WMHS Privacy Officer if you:

1. Have questions about this Notice or WMHS privacy practices.
2. Want to exercise a privacy right described in this Notice.
3. Want to request access to, a copy of, or a correction to your health information.
4. Want to request confidential communications or restrictions on disclosures.
5. Believe your privacy rights may have been violated. Wombat Mental Health Services, LCSW PC Attention: Privacy Officer 9431 Haven Avenue Rancho Cucamonga, CA 91730 Phone: (909) 529-8965 General questions: Info@WombatMHS.com Privacy complaints and concerns: Grievances@WombatMHS.com You may file a complaint directly with WMHS. Filing a complaint will not affect your eligibility for services or the care you receive. WMHS will not retaliate against you for submitting a question, concern, request, or complaint. U.S. Department of Health and Human Services You may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights: Online: https://www.hhs.gov/hipaa/filing-a-complaint/ Phone: 1-877-696-6775 Mail: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Washington, DC 20201 WMHS will not retaliate against you for filing a complaint with the Office for Civil Rights. You are not required to file a complaint with WMHS before contacting the Office for Civil Rights.

VIII. Acknowledgment of Receipt

This acknowledgment confirms that Wombat Mental Health Services, LCSW PC provided you with its Notice of Privacy Practices. Acknowledging receipt does not mean that you agree to any special use or disclosure of your health information. You may decline to sign this acknowledgment, and declining will not affect your eligibility for services or the care you receive. If you decline, WMHS will document its good-faith effort to provide you with the Notice. Please select one: (select one) I acknowledge that I received the WMHS Notice of Privacy Practices. I received the Notice but decline to sign the acknowledgment. I understand that this will not affect my services or care.

Your selection above documents acknowledgment of receipt of the Notice. Your signature below confirms receipt only; it does not indicate consent to or agreement with any special use or disclosure of your health information. Name of person completing this acknowledgment *

If completing this form for the patient, state your relationship and authority to act for them

Signature acknowledging receipt of the Notice—not consent or agreement * Your signature below verifies that you made the selection above. If you selected acknowledgment, your signature acknowledges receipt of the Notice. If you selected decline, your signature documents your decision to decline the acknowledgment. In either case, your signature does not indicate consent to or agreement with any special use or disclosure of your health information.