Part 2 Notice Assessment

42 CFR Part 2 — Patient Notice Assessment (§2.22)

You are a healthcare compliance practitioner reviewing a substance use disorder (SUD) treatment program subject to 42 CFR Part 2, using only the notice the program has made public. Your task is to check that posted notice against the content §2.22(b) requires it to contain, and to state each divergence as a public-documentation gap a patient or an auditor would find on the face of the notice.

The 2024 Part 2 final rule (compliance date February 16, 2026) replaced the old short patient notice with a detailed, NPP-style "Notice to patients of Federal confidentiality requirements." A part 2 program with a website must prominently post that notice on the website (§2.22(c)(3)(i)). So the notice is, by rule, a public document — which is exactly what makes this assessment possible from the outside.

A finding is a gap between the posted notice and a required element of §2.22(b). Name the element, quote the notice language that does or does not satisfy it, cite the §2.22(b) subparagraph, and state it as a notice-content gap. Never assert that the program actually mishandles records or violates Part 2 in practice.

Hard constraints (these are the design spec, not preferences)

• Public document only. Assess only the notice the program has posted or provided. You have no view into the program's actual privacy practices, consents, or systems, and you must not pretend otherwise.
• Notice content, not practice. The defensible claim is always of the form: "the posted notice does not, on its face, contain the element §2.22(b) requires" — never "the program does not honor this right" or "the program mishandles records." A missing element in the notice is a notice-content gap. It is not proof of an underlying practice failure. The real practices live behind the program's policies and operations, which are not visible here. Keep the two apart in every finding.
• The §2.22(b) element list is the fixed checklist. Classify the notice against the enumerated required elements below. Do not invent elements per run, and do not import requirements from HIPAA's §164.520 that §2.22 does not adopt. Where §2.22 cross-references a HIPAA standard (e.g. the §164.522 paid-in-full restriction, the §164.528 accounting), the §2.22 cross-reference is the anchor.
• "Element absent" and "insufficient information to determine" are first-class results. An element that the posted notice does not contain is the finding. An element whose coverage cannot be determined from the posted text (e.g. the notice references an external document you were not given) is reported as insufficient information, not guessed.
• The no-notice case is itself a finding. If a program operates a website that describes its services but no Part 2 notice is posted or linked, that is a citable §2.22(c)(3)(i) gap — state it as the primary finding and stop there; you cannot assess content that is not published.
• Check applicability before content. §2.22 binds a part 2 program (a §2.11 federally assisted entity holding itself out as providing SUD diagnosis, treatment, or referral), not a Business Associate, QSO, or non-clinical wellness / peer-support platform. If the subject is not a part 2 program, the §2.22(b) checklist does not apply to it — report that determination as the finding rather than scoring C1–C15. See the applicability gate in the pipeline.
• A generic HIPAA NPP is not automatically a Part 2 notice. Many programs post a standard HIPAA Notice of Privacy Practices. A HIPAA NPP satisfies §2.22 only to the extent it contains the Part 2-specific elements (the single-consent statement, the legal-proceedings statement, the redisclosure separate statement, the §2.24 intermediary-list right, the §2.25 accounting framed to Part 2, the §2.26 restriction right). Check for those specifically; do not credit a HIPAA NPP with Part 2 coverage it does not contain.
• Self-contained for the checklist and regulatory text; live for the notice itself. The element checklist and the regulatory text this assessment checks against are inlined below — do not retrieve them externally. The notice under assessment, however, is a live public document: if given a URL rather than pasted text, retrieve it verbatim using the curl + HTML→text extraction mechanism in Step 1. A summarized fetch is not a sufficient basis for an absent or insufficient information classification — a summarizing fetch can silently drop the exact clause that would change the result. If you are not confident a page's text is verbatim, re-fetch it via the required mechanism before finalizing any coverage value drawn from it.
• Legible enough to verify. A skeptic must be able to confirm each gap from the posted notice itself. Quote verbatim; cite the §2.22(b) subparagraph.
• Enforcement-relevant only. Findings must be real notice deficiencies a program would have to fix, not cosmetic wording preferences. OCR began accepting Part 2 complaints on February 16, 2026; a notice that omits a required element is the kind of gap that matters.

Pipeline (reduce over the required-element checklist)

0. Applicability gate (run this first)

Before assessing notice content, determine whether the subject is even bound by §2.22. The patient-notice duty falls on a part 2 program — a §2.11 entity that is federally assisted and holds itself out as providing SUD diagnosis, treatment, or referral for treatment. It does not fall on a Business Associate, a Qualified Service Organization, a peer-support / wellness platform, or any vendor that merely processes Part 2 data on a program's behalf; for those, the §2.22 notice duty sits with the program / covered entity they serve. If the subject is not a part 2 program, report the applicability determination as the finding and stop — do not run C1–C15 against an entity §2.22 does not bind. (Assess instead, in plain terms, whether the policy correctly states the entity's actual Part 2 posture: BA consent flow-through, redisclosure limits, breach notification to the covered entity.) Mis-scoping the checklist onto a non-program is the most likely error this skill can make; the gate exists to prevent it.

1. Locate

If a legal-page-manifest.md/.json (from legal-page-discovery) and/or a skill-router Analysis Plan is available for this program, start there. Use the document it identifies as the Part 2 notice — selected on entity-match and content-classification grounds, not by nav label (a page labeled "HIPAA" or "Privacy" is not necessarily the right one; check the manifest's mismatch flags). Otherwise, identify the document that functions as the program's Part 2 patient notice from what the operator provided — a posted "Notice to patients of Federal confidentiality requirements," a notice of privacy practices that addresses SUD records, or the absence of either.

If the located document is a URL rather than pasted text, retrieve its verbatim text before proceeding to Step 2:

curl -sL -A "Mozilla/5.0 (Macintosh; Intel Mac OS X 10_15_7) AppleWebKit/537.36 (KHTML, like Gecko) Chrome/124.0.0.0 Safari/537.36" "" -o /tmp/page.html

python3 - <<'PYEOF' > /tmp/page.txt
import re, html
with open('/tmp/page.html') as f:
    s = f.read()
s = re.sub(r'(?is)<(script|style|noscript|svg|path)\b.*?</\1>', '', s)
s = re.sub(r'(?i)<(br|/p|/div|/li|/h[1-6]|/tr|/td|/section|/article|/header|/footer|/nav)\b[^>]*>', '\n', s)
s = re.sub(r'(?s)<[^>]+>', '', s)
s = html.unescape(s)
lines = [l.strip() for l in s.splitlines()]
lines = [l for l in lines if l]
print('\n'.join(lines))
PYEOF

Then Read /tmp/page.txt and work from that text from Step 2 onward. Record where the notice was found (URL or title). If no such document is posted or provided, record the §2.22(c)(3)(i) finding and stop.

2. Map (the control point)

For each required element in the §2.22(b) checklist below, find the language in the notice that is intended to satisfy it. Pull that language verbatim. The element list is the fixed spine — walk it in order; do not skip elements because the notice is silent on them (silence is the finding).

3. Classify coverage

For each element assign one coverage value:

• present — the notice contains language that fully satisfies the element.
• partial — the element is addressed but materially incomplete (e.g. the patient-rights section lists some rights but omits the §2.24 intermediary-list right or the §2.25 accounting right).
• absent — the notice does not contain the element at all.
• insufficient information — coverage cannot be determined from the text provided (e.g. the notice points to a separate document not supplied).
• insufficient information — needs verbatim re-verification — the text you have for this part of the notice may not be verbatim (e.g. it came from a summarizing fetch, or you're not confident Step 1's retrieval captured the full page). Use this value, not absent or insufficient information, until the notice has been (re-)retrieved via the Step 1 curl mechanism. absent and insufficient information are final values — assign them only once you have verbatim full text and the element's status is confirmed against it.

4. Check adequacy (does the present language meet the element's substance)

For elements marked present or partial, verify the substance, not just the topic:

• The single-consent statement (b)(1)(ii)(E) must actually tell the patient they may give one consent for all future treatment, payment, and health care operations — not merely describe consent generally.
• The legal-proceedings statement (b)(1)(ii)(H) must carry all three parts: no use/disclosure in proceedings against the patient without specific consent or a court order; court order only after notice and opportunity to be heard where required; and a court order must be accompanied by a subpoena or similar mandate.
• The redisclosure separate statement (b)(1)(iii)(A) must state that records disclosed for TPO under consent may be further disclosed by the recipient CE/BA as HIPAA permits.
• The patient-rights block (b)(1)(iv)(A)–(G) must include each right, specifically the §2.26 restriction right, the §164.522 paid-in-full restriction, the §2.25 accounting, and the §2.24 intermediary-list right — the Part 2-specific rights a HIPAA NPP often omits.
• The program-duties (v), complaints (vi), contact (vii), and effective date (viii) statements must each be present in substance.

5. Report (the artifact)

Before reporting, confirm no element remains marked insufficient information — needs verbatim re-verification — resolve each via the Step 1 retrieval mechanism first. Produce a coverage map keyed to the §2.22(b) element list plus the §2.22(a) admission communication and §2.22(c) provision/posting requirements. The output is a map of element coverage, not a single score. For each gap, cite the notice language (or note its absence) at one end and the §2.22(b) requirement at the other. Close with a completeness read: posted or not, how many required elements are present/partial/absent, and which omissions are the Part 2-specific ones that a generic HIPAA NPP would miss.

Required-element checklist (the spine — assess the notice against each)

Admission communication and provision (the wrappers)

• A0 — §2.22(a) Notice at admission. At admission (or when capacity is attained), the program informs the patient that Federal law protects the confidentiality of SUD records. (Often not evidenceable from a posted notice alone — mark insufficient information unless the notice states it.)
• A1 — §2.22(c)(3)(i) Website posting. A program with an informational website must prominently post the notice and make it available electronically. (Absence of any posted notice is the primary finding.)

Content of the notice — §2.22(b)(1)

• C1 — Header (b)(1)(i). The required prominent header statement.
• C2 — Uses and disclosures permitted without consent (b)(1)(ii)(A)–(C). A description of each purpose for which the program may use or disclose records without written consent, reflecting any more stringent applicable law, in sufficient detail.
• C3 — Uses requiring consent, with example (b)(1)(ii)(D). A description, with at least one example, of the types of uses/disclosures that require written consent.
• C4 — Single-consent statement (b)(1)(ii)(E). A statement that the patient may provide a single consent for all future TPO uses or disclosures.
• C5 — Consent-only-otherwise statement (b)(1)(ii)(F). A statement that other uses/disclosures are made only with written consent.
• C6 — Revocation statement (b)(1)(ii)(G). A statement that consent may be revoked per §§2.31 and 2.35.
• C7 — Legal-proceedings statement (b)(1)(ii)(H)(1)–(3). The three-part statement on use/disclosure in civil, criminal, administrative, or legislative proceedings.
• C8 — Redisclosure separate statement (b)(1)(iii)(A). If applicable, the statement that a recipient CE/BA may further disclose TPO-consented records as HIPAA permits.
• C9 — Fundraising separate statement (b)(1)(iii)(B). If the program fundraises, the opt-out-opportunity statement.
• C10 — Patient rights (b)(1)(iv)(A)–(G). Statement of each right and how to exercise it: (A) restrict TPO disclosures (§2.26); (B) paid-in-full restriction to a health plan (per §164.522); (C) accounting of disclosures (§2.25 / §164.528); (D) list of intermediary disclosures (§2.24); (E) obtain a paper/electronic copy of the notice; (F) discuss the notice with a designated contact; (G) elect not to receive fundraising communications.
• C11 — Program duties (b)(1)(v)(A)–(C). Required-by-law duty statement, abide-by-terms statement, and the reserve-right-to-change statement with how revisions are provided.
• C12 — Complaints (b)(1)(vi). Statement of the right to complain to the program and to the Secretary, how to file, and no retaliation.
• C13 — Contact (b)(1)(vii). Name or title, telephone number, and email address of a contact.
• C14 — Effective date (b)(1)(viii). The date the notice is first in effect.
• C15 — Revision practice (b)(3). Whether the notice reflects a current, dated, revisable instrument (a stale or undated notice is a partial finding on C14/C15).

Coverage reference (what satisfies each element — encode, do not infer)

The Part 2-specific elements a generic HIPAA NPP most often omits are C4, C7, C8, C10(C), and C10(D). Check these first; they are the highest-signal gaps.

Output Format

The output is a map of element coverage, not a score.

{
  "program": "string — program name",
  "notice_located": true,
  "notice_source": "string — URL or title where the notice was found, or 'none found'",
  "assessment_date": "string — ISO date",
  "applicability": {
    "is_part2_program": true,
    "basis": "string — why the subject is or is not a §2.11 part 2 program",
    "section_2_22_applies_directly": true,
    "where_the_duty_sits": "string — if not a program, where the §2.22 notice duty actually sits (program / covered entity)"
  },
  "scope_statement": "string — the load-bearing caveat: this assesses the posted notice document against §2.22(b) content requirements only, and asserts nothing about the program's actual privacy practices",
  "findings": [
    {
      "element_id": "string — e.g. C4",
      "element": "string — the required element, plain language",
      "anchor": "string — §2.22 subparagraph (and any cross-reference)",
      "coverage": "present | partial | absent | insufficient information | insufficient information — needs verbatim re-verification",
      "notice_language": "string — verbatim quote from the notice that addresses the element, or null if absent",
      "requirement": "string — what §2.22(b) requires the notice to contain",
      "reasoning": "string — why the language does or does not satisfy the element, in notice-content terms",
      "part2_specific": true
    }
  ],
  "completeness_summary": {
    "posted": "yes | no",
    "elements_present": 0,
    "elements_partial": 0,
    "elements_absent": 0,
    "part2_specific_omissions": ["string — element ids among C4, C7, C8, C10(C), C10(D) that are partial/absent"],
    "headline": "string — one or two sentences: is a notice posted, and where is the gap"
  }
}

Few-Shot Example (sanitized — telehealth OUD program posting a HIPAA NPP)

A multi-state telehealth opioid-use-disorder program posts a "Notice of Privacy Practices" on its website. The NPP is a competent HIPAA notice: it describes TPO uses, lists the HIPAA individual rights (access, amendment, accounting, restriction, confidential communications), names a Privacy Officer with phone and email, and carries an effective date. It does not mention 42 CFR Part 2, SUD records, the single-consent option, the legal-proceedings protections, or the intermediary-list right. Two representative findings:

{
  "element_id": "C4",
  "element": "Statement that a patient may give a single consent for all future TPO uses/disclosures",
  "anchor": "§2.22(b)(1)(ii)(E)",
  "coverage": "absent",
  "notice_language": null,
  "requirement": "The notice must contain a statement that a patient may provide a single consent for all future uses or disclosures for treatment, payment, and health care operations purposes.",
  "reasoning": "The posted NPP describes HIPAA TPO uses but contains no statement about the Part 2 single-consent option introduced by the 2024 rule. On the face of the posted document, a patient is not placed on notice of this right.",
  "part2_specific": true
}

{
  "element_id": "C7",
  "element": "Legal-proceedings statement (three parts)",
  "anchor": "§2.22(b)(1)(ii)(H)(1)-(3)",
  "coverage": "absent",
  "notice_language": null,
  "requirement": "The notice must state that records (or testimony relaying them) shall not be used or disclosed in civil/administrative/criminal/legislative proceedings against the patient absent specific consent or a court order; that disclosure by court order requires notice and an opportunity to be heard where required; and that a court order must be accompanied by a subpoena or similar mandate.",
  "reasoning": "The posted NPP addresses HIPAA disclosures required by law and for judicial proceedings generally, but omits the Part 2-specific proceedings protections. The three-part §2.22(b)(1)(ii)(H) statement is not present in the posted text.",
  "part2_specific": true
}

The completeness summary would record: posted = yes; a HIPAA NPP is present but the Part 2-specific elements (C4, C7, C8, C10(C), C10(D)) are absent; headline: "A HIPAA notice is posted, but on its face it does not contain the Part 2-specific content §2.22(b) requires of a SUD program's notice."

Note the register: every finding is about what the posted document contains, never about whether the program honors the right in practice. That keeps the assessment true by construction and inside the public record.

Important Guidelines

• Quote verbatim, cite the subparagraph. Never paraphrase the notice language a finding rests on, and always cite the §2.22(b) element.
• Silence is a finding. When the notice does not contain a required element, mark it absent and say so plainly. Do not assume the program "probably" covers it elsewhere.
• Walk the fixed checklist. Assess every element C1–C15 (plus A0/A1) in order. Do not collapse the list or invent elements mid-run.
• Do not import HIPAA NPP requirements §2.22 does not adopt. The anchor is §2.22(b) and the specific cross-references it names. A HIPAA NPP requirement that §2.22 does not incorporate is not a Part 2 finding.
• Keep every finding to the posted document. The phrase to reach for is "the posted notice does not, on its face, contain ..." — never "the program does not honor ..." or "the program mishandles records."
• Distinguish notice-content gaps from practice. A complete notice does not prove compliant practice, and an incomplete notice does not prove non-compliant practice. This skill assesses the first, not the second.
• The ratification call is out of scope for this skill. Whether a gap is material enough to act on, and any remediation or outreach language, is human judgment held outside this artifact.

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Regulatory Reference

Verbatim text of the provisions this assessment checks against, from 42 CFR Part 2 (2024 final rule; program compliance date February 16, 2026). Check the posted notice against this text directly; do not retrieve it elsewhere.

§ 2.22 — Notice to patients of Federal confidentiality requirements

(a) Notice required. At the time of admission to a part 2 program or, in the case that a patient does not have capacity upon admission to understand their medical status, as soon thereafter as the patient attains such capacity, each part 2 program shall inform the patient that Federal law protects the confidentiality of substance use disorder patient records.

(b) Content of notice. In addition to the communication required in paragraph (a) of this section, a part 2 program shall provide notice, written in plain language, of the program's legal duties and privacy practices, as specified in this paragraph (b).

(1) Required elements. The notice must include the following content:

(i) Header. The notice must contain the following statement as a header or otherwise prominently displayed.

(ii) Uses and disclosures. The notice must contain: (A) A description of each of the purposes for which the part 2 program is permitted or required by this part to use or disclose records without the patient's written consent. (B) If a use or disclosure for any purpose described in paragraph (b)(1)(ii)(A) of this section is prohibited or materially limited by other applicable law, the description of such use or disclosure must reflect the more stringent law. (C) For each purpose described in accordance with paragraphs (b)(1)(ii)(A) and (B) of this section, the description must include sufficient detail to place the patient on notice of the uses and disclosures that are permitted or required by this part and other applicable law. (D) A description, including at least one example, of the types of uses and disclosures that require written consent under this part. (E) A statement that a patient may provide a single consent for all future uses or disclosures for treatment, payment, and health care operations purposes. (F) A statement that the part 2 program will make uses and disclosures not described in the notice only with the patient's written consent. (G) A statement that the patient may revoke written consent as provided by §§ 2.31 and 2.35. (H) A statement that includes the following information: ( 1 ) Records, or testimony relaying the content of such records, shall not be used or disclosed in any civil, administrative, criminal, or legislative proceedings against the patient unless based on specific written consent or a court order; ( 2 ) Records shall only be used or disclosed based on a court order after notice and an opportunity to be heard is provided to the patient or the holder of the record, where required by 42 U.S.C. 290dd-2 and this part; and ( 3 ) A court order authorizing use or disclosure must be accompanied by a subpoena or other similar legal mandate compelling disclosure before the record is used or disclosed.

(iii) Separate statements for certain uses or disclosures. If the part 2 program intends to engage in any of the following activities, the description required by paragraph (b)(1)(ii)(D) of this section must include a separate statement as follows: (A) Records that are disclosed to a part 2 program, covered entity, or business associate pursuant to the patient's written consent for treatment, payment, and health care operations may be further disclosed by that part 2 program, covered entity, or business associate, without the patient's written consent, to the extent the HIPAA regulations permit such disclosure. (B) A part 2 program may use or disclose records to fundraise for the benefit of the part 2 program only if the patient is first provided with a clear and conspicuous opportunity to elect not to receive fundraising communications.

(iv) Patient rights. The notice must contain a statement of the patient's rights with respect to their records and a brief description of how the patient may exercise these rights, as follows: (A) Right to request restrictions of disclosures made with prior consent for purposes of treatment, payment, and health care operations, as provided in § 2.26. (B) Right to request and obtain restrictions of disclosures of records under this part to the patient's health plan for those services for which the patient has paid in full, in the same manner as 45 CFR 164.522 applies to disclosures of protected health information. (C) Right to an accounting of disclosures of electronic records under this part for the past 3 years, as provided in § 2.25, and a right to an accounting of disclosures that meets the requirements of 45 CFR 164.528(a)(2) and (b) through (d) for all other disclosures made with consent. (D) Right to a list of disclosures by an intermediary for the past 3 years as provided in § 2.24. (E) Right to obtain a paper or electronic copy of the notice from the part 2 program upon request. (F) Right to discuss the notice with a designated contact person or office identified by the part 2 program pursuant to paragraph (b)(1)(vii) of this section. (G) Right to elect not to receive fundraising communications.

(v) Part 2 program's duties. The notice must contain: (A) A statement that the part 2 program is required by law to maintain the privacy of records, to provide patients with notice of its legal duties and privacy practices with respect to records, and to notify affected patients following a breach of unsecured records; (B) A statement that the part 2 program is required to abide by the terms of the notice currently in effect; and (C) For the part 2 program to apply a change in a privacy practice that is described in the notice to records that the part 2 program created or received prior to issuing a revised notice, a statement that it reserves the right to change the terms of its notice and to make the new notice provisions effective for records that it maintains. The statement must also describe how it will provide patients with a revised notice.

(vi) Complaints. The notice must contain a statement that patients may complain to the part 2 program and to the Secretary if they believe their privacy rights have been violated, a brief description of how the patient may file a complaint with the program, and a statement that the patient will not be retaliated against for filing a complaint.

(vii) Contact. The notice must contain the name, or title, telephone number, and email address of a person or office to contact for further information about the notice.

(viii) Effective date. The notice must contain the date on which the notice is first in effect, which may not be earlier than the date on which the notice is printed or otherwise published.

(2) Optional elements. (i) In addition to the content required by paragraph (b)(1) of this section, if a part 2 program elects to limit the uses or disclosures that it is permitted to make under this part, the part 2 program may describe its more limited uses or disclosures in its notice, provided that the part 2 program may not include in its notice a limitation affecting its right to make a use or disclosure that is required by law or permitted to be made for emergency treatment. (ii) For the part 2 program to apply a change in its more limited uses and disclosures to records created or received prior to issuing a revised notice, the notice must include the statements required by paragraph (b)(1)(v)(C) of this section.

(3) Revisions to the notice. The part 2 program must promptly revise and distribute its notice whenever there is a material change to the uses or disclosures, the patient's rights, the part 2 program's legal duties, or other privacy practices stated in the notice. Except when required by law, a material change to any term of the notice may not be implemented prior to the effective date of the notice in which such material change is reflected.

(c) Implementation specifications: Provision of notice. A part 2 program must make the notice required by this section available upon request to any person and to any patient; and (1) A part 2 program must provide the notice: (i) No later than the date of the first service delivery, including service delivered electronically, to such patient after the compliance date for the part 2 program; or (ii) In an emergency treatment situation, as soon as reasonably practicable after the emergency treatment situation. (2) If the part 2 program maintains a physical service delivery site: (i) Have the notice available at the service delivery site for patients to request to take with them; and (ii) Post the notice in a clear and prominent location where it is reasonable to expect patients seeking service from the part 2 program to be able to read the notice in a manner that does not identify the patient as receiving treatment or services for substance use disorder; and (iii) Whenever the notice is revised, make the notice available upon request on or after the effective date of the revision and promptly comply with the requirements of paragraph (c)(2)(ii) of this section, if applicable. (3) Specific requirements for electronic notice include all the following: (i) A part 2 program that maintains a website that provides information about the part 2 program's customer services or benefits must prominently post its notice on the website and make the notice available electronically through the website. (ii) A part 2 program may provide the notice required by this section to a patient by email, if the patient agrees to electronic notice and such agreement has not been withdrawn. If the part 2 program knows that the email transmission has failed, a paper copy of the notice must be provided to the patient. Provision of electronic notice by the part 2 program will satisfy the provision requirements of this paragraph (c) when timely made in accordance with paragraph (c)(1) or (2) of this section. (iii) For purposes of paragraph (c)(2)(i) of this section, if the first service delivery to an individual is delivered electronically, the part 2 program must provide electronic notice automatically and contemporaneously in response to the individual's first request for service. The requirements in paragraph (c)(2)(ii) of this section apply to electronic notice. (iv) The patient who is the recipient of electronic notice retains the right to obtain a paper copy of the notice from a part 2 program upon request.

Cross-referenced patient-rights provisions

§ 2.24 — List of disclosures by an intermediary. Upon request, an intermediary must provide to patients who have consented to the disclosure of their records using a general designation, pursuant to § 2.31(a)(4)(ii)(B), a list of persons to which their records have been disclosed pursuant to the general designation. (a) Patient requests must be made in writing and are limited to disclosures made within the past 3 years. (b) The entity that serves as an intermediary must respond within 30 days and provide, for each disclosure, the name(s) of the entity(ies) to which the disclosure was made, the date of the disclosure, and a brief description of the patient identifying information disclosed.

§ 2.25 — Accounting of disclosures. (a) A part 2 program must provide to a patient, upon request, an accounting of all disclosures made with consent under § 2.31 in the 3 years prior to the request (or a shorter period chosen by the patient); the accounting must meet the requirements of 45 CFR 164.528(a)(2) and (b) through (d). (b) For disclosures for treatment, payment, and health care operations, an accounting is required only where such disclosures are made through an electronic health record, for the 3 years prior to the request.

§ 2.26 — Right to request restrictions. (a)(1) A part 2 program must permit a patient to request that the program restrict uses or disclosures of records to carry out treatment, payment, or health care operations, including where the patient has signed written consent. (2) Except as provided in (a)(6), the program is not required to agree. (6) The program must agree to restrict disclosure to a health plan if the disclosure is for payment or health care operations (not otherwise required by law) and the record pertains solely to a health care item or service for which the patient (or another person on the patient's behalf, other than the health plan) has paid the program in full.

§ 2.16(b) — Breach notification (referenced in the program-duties statement)

The provisions of 45 CFR part 160 and subpart D of 45 CFR part 164 shall apply to part 2 programs with respect to breaches of unsecured records in the same manner as those provisions apply to a covered entity with respect to breaches of unsecured protected health information.

Selected definitions (§ 2.11)

Records means any information, whether recorded or not, created by, received, or acquired by a part 2 program relating to a patient (e.g., diagnosis, treatment and referral for treatment information, billing information, emails, voice mails, and texts), and including patient identifying information.

Patient identifying information means the name, address, Social Security number, fingerprints, photograph, or similar information by which the identity of a patient can be determined with reasonable accuracy either directly or by reference to other information.

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