Common use of Right to a Paper Copy of This Notice Clause in Contracts

Right to a Paper Copy of This Notice. You may ask us for a paper copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are entitled to receive a paper copy of this Notice. To obtain a paper copy of this Notice, ask any member of staff.. You have the right to file a complaint if you believe that staff has not complied with the practices outlined in this Notice. All complaints must be submitted in writing. You will not be penalized in any way for filing a complaint. If you believe your privacy rights have been violated, you may file a complaint with the NorCal CA 516 Continuum of Care System Administrator. To file a complaint with the Administrative Entity, contact: City of Xxxxxxx, 000 Xxxxxxx Xxx. Redding, CA 96001 Email: xxxxxxxxx@xxxxxxxxxxxxx.xxx To file a complaint with the State of California, contact: xxx.xxxxxxx.xx.xxx 000-000-0000 000-000-0000 ACKNOWLEDGEMENT OF RECEIPT By signing this form, you acknowledge receipt of the HMIS Notice of Privacy Practices. Our Notice of Privacy Practices provides information about how we may use and disclose your protected information. We encourage you to read it in full. Our Notice of Privacy Practices is subject to change. If we change our notice, you may obtain a copy of the revised notice by accessing our web site, xxxxx://xxx.xxxxxxxxxxxxxxx.xxx/hmis or by contacting any staff person involved in your services. If you have any questions about our Notice of Privacy Practices, please contact: United Way of Northern California 0000 Xxxxx Xxxxx Xx, Xxxxxxx, XX 00000 (000) 000-0000 I acknowledge receipt of the HMIS Notice of Privacy Practices. Client Signature Client Name Printed Date Inability to Obtain Acknowledgement To be completed only if no signature is obtained. If it is not possible to obtain the client’s acknowledgement, describe the good faith efforts made to obtain the client’s acknowledgement, and the reasons why the acknowledgement was not obtained: Staff Member’s Signature Staff Name and Title Printed Date Revs. 01/2024 EXHIBIT E ANTI-LOBBYING CERTIFICATION The undersigned certifies, to the best of his or her knowledge and belief, that:

Right to a Paper Copy of This Notice. You may ask us for a paper copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are entitled to receive a paper copy of this Notice. To obtain a paper copy of this Notice, ask any member staff person. You may also obtain a copy of staff.. this Notice at our website xxx.xxxxxx.xxx. San Diego County CoC Homeless Management Information System (HMIS) Notice of Privacy Practices COMPLAINTS You have the right to file a complaint if you believe that RTFH staff has not complied with the practices outlined in this Notice. All complaints must be submitted in writing. You will not be penalized in any way for filing a complaint. If you believe your privacy rights have been violated, you may file a complaint with the NorCal CA 516 Continuum of Care System AdministratorRTFH. To file a complaint with the Administrative EntityRTFH, contact: City of XxxxxxxRegional Task Force on the Homeless 0000 Xxxxxx Xxxxxx Rd., 000 Xxxxxxx Xxx. ReddingSan Diego, CA 96001 Email: xxxxxxxxx@xxxxxxxxxxxxx.xxx 92123 858-292-7627 To file a complaint with the State of California, contact: xxx.xxxxxxx.xx.xxx 000-000-0000 000-000-0000 ACKNOWLEDGEMENT OF RECEIPT By signing this form, you acknowledge receipt of the HMIS Notice of Privacy Practices. Our Notice of Privacy Practices provides information about how we may use and disclose your protected information. We encourage you to read it in full. Our Notice of Privacy Practices is subject to change. If we change our notice, you may obtain a copy of the revised notice by accessing our web site, xxxxx://xxx.xxxxxxxxxxxxxxx.xxx/hmis xxxx://xxx.xxxxxx.xxx/ or by contacting any staff person involved in your services. If you have any questions about our Notice of Privacy Practices, please contact: United Way of Northern California Regional Task Force on the Homeless 0000 Xxxxx Xxxxx XxXxxxxx Xxxxxx Rd., XxxxxxxSan Diego, XX 00000 (000) 000CA 92123 858-0000 292-7627 I acknowledge receipt of the HMIS Notice of Privacy Practices. Client Signature Client Name Name, Printed Date Inability to Obtain Acknowledgement To be completed only if no signature is obtained. If it is not possible to obtain the client’s acknowledgement, describe the good faith efforts made to obtain the client’s acknowledgement, and the reasons why the acknowledgement was not obtained: Staff Member’s Signature Staff Name and Title Printed Date RevsSan Diego County CoC Homeless Management Information System (HMIS)‌ Summary of Privacy Practices THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED SHARED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. 01/2024 EXHIBIT E ANTI-LOBBYING CERTIFICATION The undersigned certifiesPLEASE READ IT CAREFULLY Effective Date: Our Duty to Safeguard Your Protected Information [ENTER AGENCY NAME HERE] collects information about who uses our services. We will ask for your permission to enter the information we collect about you and your family into a computer program called the Homeless Management Information System (HMIS) for the use of housing and services. Although the HMIS helps us to keep track of your information, individually identifiable information about you is considered “Protected Information.” We are required to protect the best privacy of his your identifying information and to give you notice about how, when and why we may use or her knowledge disclose any information you may give us. We are also required to follow the privacy practices described in this Notice, although [ENTER AGENCY NAME HERE] reserves the right to change our privacy practices and beliefthe terms of this notice at any time. You may request a copy of the notice from any agency that participates in the HMIS. How We May Use and Share Your Information We use and share collective information for a variety of reports. We have a limited right to include some of your information for reports on homelessness. Information that could be used to tell who you are will never be used for these reports. We will not turn your information over to a state, that:local, private, or national database without your consent. We must have your written consent to use or disclose your information unless the law permits or requires us to make the use or disclosure without your permission. Please review the Client Consent to Share and/or Disclose Information for details. You must sign this form before we can use your information, but you do not have to sign the form in order to receive services.

Right to a Paper Copy of This Notice. You have the right to receive a paper copy of this Notice. You may ask us for to give you a paper copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to receive a paper copy of this Notice. To obtain a paper copy of QUESTIONS OR COMPLAINTS If you have any questions regarding this NoticeNotice or wish to receive additional information about our privacy practices, ask any member of staff.. You have please contact our Privacy Officer at the right to file a complaint if you believe that staff has not complied with the practices outlined in this Notice. All complaints must be submitted in writing. You will not be penalized in any way for filing a complaintaddress below. If you believe your privacy rights have been violated, you may file a complaint with our office or with the NorCal CA 516 Continuum Secretary of Care System AdministratorDHHS. To file a complaint with our office, contact our Privacy Officer at the Administrative Entity, contact: City of Xxxxxxx, 000 Xxxxxxx Xxxaddress below. Redding, CA 96001 Email: xxxxxxxxx@xxxxxxxxxxxxx.xxx To file All complaints must be submitted in writing. You will not be penalized for filing a complaint with the State of complaint. Xxxx Xxxxx Covenant Care California, contact: xxx.xxxxxxx.xx.xxx 000-000-0000 000-000-0000 ACKNOWLEDGEMENT OF RECEIPT By signing this form, you acknowledge receipt of the HMIS Notice of Privacy Practices. Our Notice of Privacy Practices provides information about how we may use and disclose your protected information. We encourage you to read it in full. Our Notice of Privacy Practices is subject to change. If we change our notice, you may obtain a copy of the revised notice by accessing our web site, xxxxx://xxx.xxxxxxxxxxxxxxx.xxx/hmis or by contacting any staff person involved in your services. If you have any questions about our Notice of Privacy Practices, please contact: United Way of Northern California 0000 LLC 00000 Xxxxx Xxxxx Xx. Suite 100 Aliso Viejo, XxxxxxxCA 92656 949.349.1200 xxxxxx@xxxxxxxxxxxx.xxx EFFECTIVE DATE OF THIS NOTICE: This Notice is effective March 1, XX 00000 2013 Appendix I: Audio and Video Policy (000Resident/Public/Facility) 000-0000 I acknowledge receipt Policy BASIC RESPONSIBILITY • Facility Administrator/Executive Director, or designee and All Facility Employees POLICY GUIDELINES • The resident has the right to privacy, confidential care, and protection of health information. • Healthcare professionals have a duty to protect each resident’s healthcare information and privacy. • Violations of the HMIS Notice of Privacy Practicesresident’s rights undermine the public’s confidence in healthcare organizations. Client Signature Client Name Printed Date Inability to Obtain Acknowledgement To be completed only if no signature is obtained. If it is not possible to obtain the client’s acknowledgement• Similarly, describe the good faith efforts made to obtain the client’s acknowledgementall persons, including residents, healthcare professionals and the reasons why the acknowledgement was not obtained: Staff Member’s Signature Staff Name and Title Printed Date Revs. 01/2024 EXHIBIT E ANTI-LOBBYING CERTIFICATION The undersigned certifies, visitors to the best facility, have an interest in how their recorded likeness, image and voice are subsequently used. In order to safeguard these identified interests, the facility does not permit photographing of his any kind or her knowledge use of audio or video recording devices, unless prior written consent is obtained from the resident and belief, that:any other persons depicted within the facility DEFINITIONS • A photographic device is any device that captures an image and outputs the resulting image on a display surface. This includes all video and still captures devices. An audio device is any device that records sound. PROCEDURAL COMPONENTS

Right to a Paper Copy of This Notice. You may ask us for a paper copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are entitled to receive a paper copy of this Notice. To obtain a paper copy of this Notice, ask any member staff person. You may also obtain a copy of staff.. this Notice at our website xxx.xxxxxx.xxx. San Diego County CoC Homeless Management Information System (HMIS) Notice of Privacy Practices COMPLAINTS You have the right to file a complaint if you believe that RTFH staff has not complied with the practices outlined in this Notice. All complaints must be submitted in writing. You will not be penalized in any way for filing a complaint. If you believe your privacy rights have been violated, you may file a complaint with the NorCal CA 516 Continuum of Care System AdministratorRTFH. To file a complaint with the Administrative EntityRTFH, contact: City of XxxxxxxRegional Task Force on the Homeless 0000 Xxxxxx Xxxxxx Rd., 000 Xxxxxxx Xxx. ReddingSan Diego, CA 96001 Email: xxxxxxxxx@xxxxxxxxxxxxx.xxx 92123 858-292-7627 To file a complaint with the State of California, contact: xxx.xxxxxxx.xx.xxx 000-000-0000 000-000-0000 ACKNOWLEDGEMENT OF RECEIPT By signing this form, you acknowledge receipt of the HMIS Notice of Privacy Practices. Our Notice of Privacy Practices provides information about how we may use and disclose your protected information. We encourage you to read it in full. Our Notice of Privacy Practices is subject to change. If we change our notice, you may obtain a copy of the revised notice by accessing our web site, xxxxx://xxx.xxxxxxxxxxxxxxx.xxx/hmis xxxx://xxx.xxxxxx.xxx/ or by contacting any staff person involved in your services. If you have any questions about our Notice of Privacy Practices, please contact: United Way of Northern California Regional Task Force on the Homeless 0000 Xxxxx Xxxxx XxXxxxxx Xxxxxx Rd., XxxxxxxSan Diego, XX 00000 (000) 000CA 92123 858-0000 292-7627 I acknowledge receipt of the HMIS Notice of Privacy Practices. Client Signature Client Name Name, Printed Date Inability to Obtain Acknowledgement To be completed only if no signature is obtained. If it is not possible to obtain the client’s acknowledgement, describe the good faith efforts made to obtain the client’s acknowledgement, and the reasons why the acknowledgement was not obtained: Staff Member’s Signature Staff Name and Title Printed Date RevsSan Diego County CoC Homeless Management Information System (HMIS) Summary of Privacy Practices THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED SHARED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. 01/2024 EXHIBIT E ANTI-LOBBYING CERTIFICATION The undersigned certifiesPLEASE READ IT CAREFULLY Effective Date: Our Duty to Safeguard Your Protected Information [ENTER AGENCY NAME HERE] collects information about who uses our services. We will ask for your permission to enter the information we collect about you and your family into a computer program called the Homeless Management Information System (HMIS) for the use of housing and services. Although the HMIS helps us to keep track of your information, individually identifiable information about you is considered “Protected Information.” We are required to protect the best privacy of his your identifying information and to give you notice about how, when and why we may use or her knowledge disclose any information you may give us. We are also required to follow the privacy practices described in this Notice, although [ENTER AGENCY NAME HERE] reserves the right to change our privacy practices and beliefthe terms of this notice at any time. You may request a copy of the notice from any agency that participates in the HMIS. How We May Use and Share Your Information We use and share collective information for a variety of reports. We have a limited right to include some of your information for reports on homelessness. Information that could be used to tell who you are will never be used for these reports. We will not turn your information over to a state, that:local, private, or national database without your consent. We must have your written consent to use or disclose your information unless the law permits or requires us to make the use or disclosure without your permission. Please review the Client Consent to Share and/or Disclose Information for details. You must sign this form before we can use your information, but you do not have to sign the form in order to receive services.