Common use of Notice of Privacy Practices Clause in Contracts

Notice of Privacy Practices. Effective April 14, 2003, as revised September 1, 2013 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. Sweetser is required by law to maintain the privacy of your health care information, to provide you with a notice of Xxxxxxxx’x legal duties and privacy practices with respect to your health care information and to notify affected individuals if there should be a breach of unsecured health information held by Sweetser. Sweetser is required to follow the terms of the privacy notice in effect at any particular time, but Sweetser reserves the right to change its privacy practices at any time. Any change will apply to all health care information maintained by Sweetser and will be set forth in a new notice of privacy practices which will be available at your next visit following the change. At any time, you may obtain a copy of the notice of privacy practices currently in effect by requesting a copy in writing from Xxxxxxxx’x Privacy Officer at the address specified below. Use and disclosure of your health care information Sweetser may use your health care information for purposes of treatment, payment and health care operations. For example: Your information may be used to assess your needs and develop an individualized service plan or to coordinate a referral to another health care provider. Portions of your information may be submitted to a state agency, insurance carrier or other third-party payer to secure payment for services provided to you, unless you have arranged personally to pay in full all charges for services provided to you. Your information may be used for operations of Sweetser related to health care activities, such as quality assurance, evaluation, training, audits and administration. Sweetser may use your health care information to contact you to remind you of an appointment or to provide information about treatment alternatives or other health services or about Sweetser and our programs. We may also use it to contact you for fundraising purposes, but if we do so, you have the right to choose not to receive subsequent fundraising communications and we will offer you the option to do so. Sweetser may disclose your health care information to another person or entity performing services on Xxxxxxxx’x behalf which relate to treatment, payment or health care operations and which require access to your information. That person or entity will have access to your information only to perform those services and must agree in writing to maintain the confidentiality of your information. Sweetser may disclose your health care information without your authorization as permitted or required by applicable law, including any of the following: to comply with public health statutes and rules; to make any required reports of abuse or neglect; to comply with health care oversight activities of a government agency (such as licensing); to comply with a court order, search warrant or other lawful process; to allow approved research projects to be conducted; to provide information to a medical examiner in the event of your death; to avert a serious threat to your or anyone else’s health or safety; or to provide information for workers’ compensation purposes. Except as described above, Sweetser will not use or disclose your health care information without your written authorization. Your written authorization will in any event be required for any use or disclosure of psychotherapy notes and for any use or disclosure of health care information which is for marketing purposes or which involves sale of your health care information. You may revoke any authorization at any time, in writing or verbally, by communicating the revocation to the clinician or caseworker principally responsible for your care or to a supervisor or manager within the program from which you receive services, or to a member of Xxxxxxxx’x Client Records Department staff. Revocation will not, however, be effective with regard to actions already taken in reliance on your authorization. Your privacy rights You may request restrictions on the use or disclosure of your health care information, but Sweetser is not required to agree to any requested restriction. It is Xxxxxxxx’x policy not to agree to such a restriction unless Sweetser determines, in its sole discretion, that there is compelling need for the restriction and the restriction can feasibly be implemented. Sweetser will, however, agree not to disclose your health care information to a health plan in order to obtain payment for services provided to you if Sweetser has received payment in full for the services from you or someone acting on your behalf. You may request that communications to you be given in a way which will help keep them confidential, for example, by using a particular address or telephone number to contact you. Sweetser will comply with such a request if it is reasonable and feasible. To request restrictions or a confidential manner of communicating, you should submit a written request to the clinician or caseworker principally responsible for your care, or to a supervisor or manager within the program from which you receive services, or to a member of Xxxxxxxx’x Client Records Department. You have the right: to receive an accounting of any disclosures of your health care information apart from ones which you authorized or which were made for treatment, payment or health care operations; to inspect and copy your health care information; to amend your health care information; and to receive a paper copy of this Notice of Privacy Practices. To exercise any of the above rights, please submit your request in writing to Xxxxxxxx’x Privacy Officer at the address below. You may also contact the Privacy Officer to obtain further information about Xxxxxxxx’x privacy policies and practices. If you believe your privacy rights have been violated, you may complain to Sweetser or to the Secretary of the U.S. Department of Health and Human Services. To file a complaint with Sweetser, please submit your complaint in writing to Xxxxxxxx’x Compliance Officer at the address below. A complaint form will be supplied on request but is not required. Nobody is permitted to retaliate against you for filing a complaint. To exercise rights or obtain information: To file a complaint with Sweetser: Privacy Officer Compliance Officer Sweetser Sweetser 00 Xxxxx Xxxxxx 00 Xxxxx Xxxxxx Saco, ME 04072 Saco, ME 04072 (000) 000-0000

Notice of Privacy Practices. Effective April 14, 2003, as revised September 1, 2013 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATIONThis section describes how health information about you may be used and disclosed and how you can get access to this information. PLEASE REVIEW IT CAREFULLYPlease review it carefully. Sweetser The privacy of your health information is important to us. Confidentiality of your health care information This notice is required by law to maintain inform you of how Delta Dental protects the privacy confidentiality of your health care informationinformation in our possession. Protected Health Information (PHI) is defined as individually identifiable information regarding a patient's health care history, mental or physical condition or treatment. Some examples of PHI include your name, address, telephone and/or fax number, electronic mail address, social security number or other identification number, date of birth, date of treatment, treatment records, x-rays, enrollment and claims records. Delta Dental receives, uses and discloses your PHI to provide you with a notice administer your benefit plan or as permitted or required by law. Any other disclosure of Xxxxxxxx’x legal duties and your PHI without your authorization is prohibited. We follow the privacy practices with respect described in this notice and federal and state privacy requirements that apply to our administration of your health care information and to notify affected individuals if there should be a breach of unsecured health information held by Sweetserbenefits. Sweetser is required to follow the terms of the privacy notice in effect at any particular time, but Sweetser Delta Dental reserves the right to change its our privacy practices practice effective for all PHI maintained. We will update this notice if there are material changes and redistribute it to you within 60 days of the change to our practices. We will also promptly post a revised notice on our website. A copy may be requested anytime by contacting the address or phone number at any timethe end of this notice. Any change will apply to all health care information maintained by Sweetser You should receive a copy of this notice at the time of enrollment in a Delta Dental program and will be set forth in a new notice of privacy practices which will be available at your next visit following the change. At any time, you may informed on how to obtain a copy of the notice of privacy practices currently in effect by requesting a copy in writing from Xxxxxxxx’x Privacy Officer at the address specified belowleast every three years. Use Permitted uses and disclosure disclosures of your health care information Sweetser may use your health care information for purposes of treatment, payment PHI Uses and health care operations. For example: Your information may be used to assess your needs and develop an individualized service plan or to coordinate a referral to another health care provider. Portions disclosures of your information may be submitted to a state agency, insurance carrier or other third-party payer to secure payment PHI for services provided to you, unless you have arranged personally to pay in full all charges for services provided to you. Your information may be used for operations of Sweetser related to health care activities, such as quality assurance, evaluation, training, audits and administration. Sweetser may use your health care information to contact you to remind you of an appointment or to provide information about treatment alternatives or other health services or about Sweetser and our programs. We may also use it to contact you for fundraising purposes, but if we do so, you have the right to choose not to receive subsequent fundraising communications and we will offer you the option to do so. Sweetser may disclose your health care information to another person or entity performing services on Xxxxxxxx’x behalf which relate to treatment, payment or health care operations Your explicit authorization is not required to disclose information about yourself, or for purposes of health care treatment, payment of claims, billing of premiums, and which require access other health care operations. If your benefit plan is sponsored by your employer or another party, we may provide PHI to your informationemployer or plan sponsor to administer your benefits. That person or entity will As permitted by law, we may also disclose PHI to third party affiliates that perform services for Delta Dental to administer your benefits. As permitted by law, we may disclose PHI to third-party affiliates that perform services for Delta Dental to administer your benefits, and who have access signed a contract agreeing to your information only to perform those services and must agree in writing to maintain protect the confidentiality of your informationPHI, and have implemented privacy policies and procedures that comply with applicable federal and state law. Sweetser Some examples of disclosure and use for treatment, payment or operations include: processing your claims, collecting enrollment information and premiums, reviewing the quality of health care you receive, providing customer service, resolving your grievances, and sharing payment information with other insurers. Some other examples are: • Uses and/or disclosures of PHI in facilitating treatment. For example, Delta Dental may use or disclose your PHI to determine eligibility for services requested by your provider. • Uses and/or disclosures of PHI for payment. For example, Delta Dental may use and disclose your PHI to bill you or your plan sponsor. • Uses and/or disclosures of PHI for health care operations. For example, Delta Dental may use and disclose your PHI to review the quality of care provided by our network of providers. Other permitted uses and disclosures without an authorization We are permitted to disclose your PHI upon your request or to your authorized personal representative (with certain exceptions) when required by the U. S. Secretary of Health and Human Services to investigate or determine our compliance with law, and when otherwise required by law. Delta Dental may disclose your health care information PHI without your prior authorization as permitted or required by applicable law, including any of in response to the following: • Court order; • Order of a board, commission, or administrative agency for purposes of adjudication pursuant to comply with public health statutes and rulesits lawful authority; to make any required reports of abuse or neglect• Subpoena in a civil action; to comply with health care oversight activities • Investigative subpoena of a government agency (such as licensing)board, commission, or agency; • Subpoena in an arbitration; • Law enforcement search warrant; or • Xxxxxxx's request during investigations. Some other examples include: to notify or assist in notifying a family member, another person, or a personal representative of your condition; to comply with a court order, search warrant or other lawful processassist in disaster relief efforts; to allow approved research projects report victims of abuse, neglect or domestic violence to be conductedappropriate authorities; to provide information to a medical examiner in the event of your deathfor organ donation purposes; to avert a serious threat to your or anyone else’s health or safety; or to provide information for specialized government functions such as military and veterans activities; for workers’ ' compensation purposes; and, with certain restrictions, we are permitted to use and/or disclose your PHI for underwriting, provided it does not contain genetic information. Except as described aboveInformation can also be de-identified or summarized so it cannot be traced to you and, Sweetser in selected instances, for research purposes with the proper oversight. Disclosures Delta Dental makes with your authorization Delta Dental will not use or disclose your health care information PHI without your written authorization. Your prior written authorization will in any event be required for any use or disclosure of psychotherapy notes and for any use or disclosure of health care information which is for marketing purposes or which involves sale of your health care informationunless permitted by law. You may can later revoke any authorization at any timethat authorization, in writing or verballywriting, by communicating to stop the revocation to the clinician or caseworker principally responsible for your care or to a supervisor or manager within the program from which you receive services, or to a member of Xxxxxxxx’x Client Records Department stafffuture use and disclosure. Revocation The authorization will not, however, be effective with regard to actions already taken in reliance on your authorization. Your privacy rights You may request restrictions on the use or disclosure of your health care information, but Sweetser is not required to agree to any requested restriction. It is Xxxxxxxx’x policy not to agree to such a restriction unless Sweetser determines, in its sole discretion, that there is compelling need for the restriction and the restriction can feasibly be implemented. Sweetser will, however, agree not to disclose your health care information to a health plan in order to obtain payment for services provided to you if Sweetser has received payment in full for the services obtained from you by Delta Dental or someone acting on by a person requesting your behalf. You may request that communications to you be given in a way which will help keep them confidential, for example, by using a particular address or telephone number to contact you. Sweetser will comply with such a request if it is reasonable and feasible. To request restrictions or a confidential manner of communicating, you should submit a written request to the clinician or caseworker principally responsible for your care, or to a supervisor or manager within the program PHI from which you receive services, or to a member of Xxxxxxxx’x Client Records Department. You have the right: to receive an accounting of any disclosures of your health care information apart from ones which you authorized or which were made for treatment, payment or health care operations; to inspect and copy your health care information; to amend your health care information; and to receive a paper copy of this Notice of Privacy Practices. To exercise any of the above rights, please submit your request in writing to Xxxxxxxx’x Privacy Officer at the address below. You may also contact the Privacy Officer to obtain further information about Xxxxxxxx’x privacy policies and practices. If you believe your privacy rights have been violated, you may complain to Sweetser or to the Secretary of the U.S. Department of Health and Human Services. To file a complaint with Sweetser, please submit your complaint in writing to Xxxxxxxx’x Compliance Officer at the address below. A complaint form will be supplied on request but is not required. Nobody is permitted to retaliate against you for filing a complaint. To exercise rights or obtain information: To file a complaint with Sweetser: Privacy Officer Compliance Officer Sweetser Sweetser 00 Xxxxx Xxxxxx 00 Xxxxx Xxxxxx Saco, ME 04072 Saco, ME 04072 (000) 000-0000Delta Dental.

Notice of Privacy Practices. Effective April 14Palco may receive and create records concerning your medical and individually identifiable information (“PHI”) and is required to maintain the privacy and security of your PHI. Please read this notice carefully. If you have questions or concerns, 2003contact the Palco Privacy Officer at xxxxxxx@xxxxxxxxxx.xxx. Palco will only use and disclose your information as allowed by law and as described below:  Help manage the health care treatment you receive. We may disclose your information to provide treatment and administer services, including performing assessments, issuing workers’ compensation and administering similar programs, and recommending services in some situations. We may disclose information to others who implement your health services. We may correspond with you and/or your designated representative (e.g., surrogate employer or authorized user). All emailed correspondence from Xxxxx is encrypted and secure. By emailing Palco with your personal email account, you accept the risk that your correspondence may not be encrypted, nor secure.  Run our business, including payment for and administration of your health services. We may use and disclose your information to receive and issue payment on your behalf and bill Medicaid, Medicare, Managed Care Organizations, the Veterans Administration, or other bodies, as revised September 1required by your program.  Comply with federal and state law, 2013 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATIONincluding investigations by the United States Department of Health and Human Services (U.S. DHHS) and law enforcement. PLEASE REVIEW IT CAREFULLY. Sweetser Palco is required by law to maintain comply with investigations by regulatory bodies and issues involving national security. Palco may be required to disclose your information to coroners and other officials at your death.  Respond to legal actions and health oversight, such as lawsuits or quality assurance reviews. Palco may be required to respond to requests, including discovery, subpoenas, audits, and other legal or regulatory matters. You have the privacy right to: • Authorize the use and disclosure of your health care informationPHI for reasons not authorized by federal or state law. Palco will seek your approval to disclose PHI for reasons not required at law, and you may reject disclosure. • Receive this notice of privacy practices. You can request a copy of this notice or view the posting at xxxxxxxxxx.xxx, in enrollment packets, and in program manuals, as applicable. Palco can change the terms of this notice at any time. Changes will apply to all of your medical records. Direct complaints to the Privacy Officer or the U.S. DHHS. • Review and receive copies of your records and a list of disclosures. Requests must be on a Request for Sensitive Records. We will provide you with a notice copy or summary within 10 days of Xxxxxxxx’x legal duties receiving your request. We may charge a reasonable, cost-based fee for collection of the records, including postage and privacy practices with respect labor. Palco may reject some requests if required by law. • Request amendments to your health care records. Requests must be on a Request to Amend Sensitive Information. We will provide you with a copy or summary or a rejection within 15 days of receiving your request. • Request information in an alternate format or restrict access on your records. Requests must be in writing on a Request for Additional Privacy. We will provide you with a copy or summary within 15 days of receiving your request. We may reject or terminate the request in certain limited cases and to will notify affected individuals if there should be you of rejections and terminations. • Be notified in case of a breach of unsecured health information held by Sweetser. Sweetser is required to follow the terms of the privacy notice in effect at any particular time, but Sweetser reserves the right to change its privacy practices at any time. Any change will apply to all health care information maintained by Sweetser and will be set forth in a new notice of privacy practices which will be available at your next visit following the change. At any time, you may obtain a copy of the notice of privacy practices currently in effect by requesting a copy in writing from Xxxxxxxx’x Privacy Officer at the address specified below. Use and disclosure of your health care information Sweetser may use your health care information for purposes of treatment, payment and health care operations. For example: Your information may be used to assess your needs and develop an individualized service plan or to coordinate a referral to another health care provider. Portions of your information may be submitted to a state agency, insurance carrier or other third-party payer to secure payment for services provided to you, unless you have arranged personally to pay in full all charges for services provided to you. Your information may be used for operations of Sweetser related to health care activities, such as quality assurance, evaluation, training, audits and administration. Sweetser may use your health care information to contact you to remind you of an appointment or to provide information about treatment alternatives or other health services or about Sweetser and our programs. We may also use it to contact you for fundraising purposes, but if we do so, you have the right to choose not to receive subsequent fundraising communications and we will offer you the option to do so. Sweetser may disclose your health care information to another person or entity performing services on Xxxxxxxx’x behalf which relate to treatment, payment or health care operations and which require access to your information. That person or entity will have access to your information only to perform those services and must agree in writing to maintain the confidentiality of your information. Sweetser may disclose your health care information without your authorization as permitted or required by applicable law, including any of the following: to comply with public health statutes and rules; to make any required reports of abuse or neglect; to comply with health care oversight activities of a government agency (such as licensing); to comply with a court order, search warrant or other lawful process; to allow approved research projects to be conducted; to provide information to a medical examiner in the event of your death; to avert a serious threat to your or anyone else’s health or safety; or to provide information for workers’ compensation purposes. Except as described above, Sweetser will not use or disclose your health care information without your written authorization. Your written authorization will in any event be required for any use or disclosure of psychotherapy notes and for any use or disclosure of health care information which is for marketing purposes or which involves sale of your health care sensitive information. You may revoke any authorization at any time, in writing or verbally, will be notified within 60 days by communicating the revocation Privacy Officer. • Choose someone to the clinician or caseworker principally responsible for act on your care or to a supervisor or manager within the program from which you receive services, or to a member of Xxxxxxxx’x Client Records Department staff. Revocation will not, however, be effective behalf with regard to actions already taken in reliance on your authorizationrecords. Your privacy rights You may request restrictions on must complete the use or disclosure of your health care information, but Sweetser is not required to agree to any requested restriction. It is Xxxxxxxx’x policy not to agree to such a restriction unless Sweetser determines, in its sole discretion, that there is compelling need for the restriction appropriate forms and the restriction can feasibly be implemented. Sweetser will, however, agree not to disclose your health care information to a health plan designate Authorized Users in order for those individuals to obtain payment for services provided to you if Sweetser has received payment in full for the services from you or someone acting communicate with Palco on your behalf. You EN-000000-NPP-1.0 PALCO SEMIMONTHLY PAYMENT SCHEDULE - 2020 Colorado CDASS Program Service Period Timesheets Due to Palco by 12:00 p.m. Payment Date Start Date End Date Deadline Paid On December 16, 2019 December 31, 2019 January 2, 2020 January 8, 2020 January 1, 2020 January 15, 2020 January 17, 2020 January 23, 2020 January 16, 2020 January 31, 2020 February 2, 2020 February 10, 2020 February 1, 2020 February 15, 2020 February 17, 2020 February 24, 2020 February 16, 2020 February 29, 2020 March 2, 2020 March 9, 2020 March 1, 2020 March 15, 2020 March 17, 2020 March 23, 2020 March 16, 2020 March 31, 2020 April 2, 2020 April 8, 2020 April 1, 2020 April 15, 2020 April 17, 2020 April 23, 2020 April 16, 2020 April 30, 2020 May 2, 2020 May 8, 2020 May 1, 2020 May 15, 2020 May 18, 2020 May 26, 2020 May 16, 2020 May 31, 2020 June 2, 2020 June 8, 2020 June 1, 2020 June 15, 2020 June 17, 2020 June 23, 2020 June 16, 2020 June 30, 2020 July 2, 2020 July 8, 2020 July 1, 2020 July 15, 2020 July 17, 2020 July 23, 2020 July 16, 2020 July 31, 2020 August 3, 2020 August 10, 2020 August 1, 2020 August 15, 2020 August 17, 2020 August 24, 2020 August 16, 2020 August 31, 2020 September 2, 2020 September 8, 2020 September 1, 2020 September 15, 2020 September 17, 2020 September 23, 2020 September 16, 2020 September 30, 2020 October 2, 2020 October 8, 2020 October 1, 2020 October 15, 2020 October 17, 2020 October 23,2020 October 16, 2020 October 31, 2020 November 2, 2020 November 9, 2020 November 1, 2020 November 15, 2020 November 17, 2020 November 23, 2020 November 16, 2020 November 30, 2020 December 2, 2020 December 8, 2020 December 1, 2020 December 15, 2020 December 18, 2020 December 23, 2020 December 16, 2020 December 31, 2020 January 2, 2021 January 8, 2021 Late time submissions and mistakes may request that communications result in late payment! Time entry can be done quickly and easy using our online portal CONNECT. Call Customer Service to you be given in a way which will help keep them confidentialregister today! 2020 Bank & Pal New Year's Day ‐ Wednesday, for exampleJanuary 1* co Office Holidays Labor Day ‐ Monday, by using a particular address or telephone number to contact youSeptember 7* Xxxxxx Xxxxxx Xxxx, Xx. Sweetser will comply with such a request if it is reasonable and feasible. To request restrictions or a confidential manner of communicatingDay ‐ Monday, you should submit a written request to the clinician or caseworker principally responsible for your careJanuary 20 Columbus Day ‐ Monday, or to a supervisor or manager within the program from which you receive servicesOctober 12 President's Day ‐ Monday, or to a member of Xxxxxxxx’x Client Records Department. You have the right: to receive an accounting of any disclosures of your health care information apart from ones which you authorized or which were made for treatmentFebruary 17 Veterans Day ‐ Wednesday, payment or health care operations; to inspect and copy your health care information; to amend your health care information; and to receive a paper copy of this Notice of Privacy Practices. To exercise any of the above rightsNovember 11 Memorial Day ‐ Monday, please submit your request in writing to Xxxxxxxx’x Privacy Officer at the address below. You may also contact the Privacy Officer to obtain further information about Xxxxxxxx’x privacy policies and practices. If you believe your privacy rights have been violatedMay 25* Thanksgiving ‐ Thursday-Friday, you may complain to Sweetser or to the Secretary of the U.S. Department of Health and Human Services. To file a complaint with SweetserNovember 26-27* Independence Day ‐ Friday, please submit your complaint in writing to Xxxxxxxx’x Compliance Officer at the address below. A complaint form will be supplied on request but is not required. Nobody is permitted to retaliate against you for filing a complaint. To exercise rights or obtain information: To file a complaint with Sweetser: Privacy Officer Compliance Officer Sweetser Sweetser 00 Xxxxx Xxxxxx 00 Xxxxx Xxxxxx SacoJuly 3* * Palco Off Christmas ‐ Thursday-Friday, ME 04072 Saco, ME 04072 (000) 000December 24-000025*ice Closures EN-060043-MPS-1.0

Notice of Privacy Practices. Effective April 14Providers and healthcare agencies are required to provide patients a notification of their privacy rights as it relates to their health care records. You received and had the opportunity to read my Privacy Notice that explains how confidential information can be transmitted, 2003shared, as revised September 1and stored. You understand that you should ask questions or discuss any concerns with her if they arise. Your signature below acknowledges that you have familiarized yourself with my HIPAA practices. If I am billing insurance for you, 2013 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATIONwith your signature below, you are authorizing assignment of payment of your mental health benefits to Xxxxx Xxxxx/Clinical Conversations, Inc. You accept, understand, and agree to abide by the contents and terms of this Client Agreement. PLEASE REVIEW IT CAREFULLYYou also consent to participate in treatment and understand that you may withdraw from treatment at any time. Sweetser is Client signature:_ Client/Parent’s signature: Therapist signature: Date: Date: Date: The Health Insurance Portability and Accountability Act of 1996 (HIPAA) has ordered the development of rules for health-related record security and privacy. I am required by law and by the NASW Code of Ethics to maintain the privacy of your health care information, information and to provide you with a this notice of Xxxxxxxx’x my legal duties and privacy practices with respect to your health care information and to notify affected individuals if there should be a breach of unsecured health information held by Sweetserinformation. Sweetser is required to follow the terms of the privacy notice in effect at any particular time, but Sweetser reserves I reserve the right to change its privacy practices the terms of this Privacy Notice at any time. Any change will apply to all health care information maintained by Sweetser time and will be set forth provide you with a copy in a new notice of privacy practices which will be available the mail upon request or providing one to you at your next visit following appointment. PRIVACY NOTICE This Privacy Notice informs you how health information about you may be used and disclosed; and how you can get access to this information. Please carefully read. It is important that you know and understand the changepatient protections HIPAA affords you. The laws and standards of my profession require that I keep treatment records which contains personal information about you and your health. At any timeall times your medical record is maintained securely. I maintain records for ten years after closing of a chart. If you wish, you your health information may obtain a copy be reviewed and disclosed to those involved in your care for the purpose of the notice of privacy practices currently in effect by requesting a copy in writing from Xxxxxxxx’x Privacy Officer at the address specified below. Use and disclosure of providing, coordinating, or managing your health care information Sweetser may use your health care information for purposes of treatment, payment treatment and health care operations. For example: Your information may be used to assess your needs and develop an individualized service plan or to coordinate a referral to another health care provider. Portions of your information may be submitted to a state agency, insurance carrier or other third-party payer to secure payment for services provided to you, unless you have arranged personally to pay in full all charges for services provided to you. Your information may be used for operations of Sweetser related to health care activities, such as quality assurance, evaluation, training, audits and administration. Sweetser may use your health care information to contact you to remind you of an appointment or to provide information about treatment alternatives or other health services or about Sweetser and our programs. We may also use it to contact you for fundraising purposes, but if we do so, you have the right to choose not to receive subsequent fundraising communications and we will offer you the option to do so. Sweetser may disclose your health care information to another person or entity performing services on Xxxxxxxx’x behalf which relate to treatment, payment or health care operations and which require access to your information. That person or entity will have access to your information only to perform those services and must agree in writing to maintain the confidentiality of your information. Sweetser may disclose your health care information without your authorization as permitted or required by applicable law, including any of the following: to comply with public health statutes and rules; to make any required reports of abuse or neglect; to comply with health care oversight activities of a government agency (such as licensing); to comply with a court order, search warrant or other lawful process; to allow approved research projects to be conducted; to provide information to a medical examiner in the event of your death; to avert a serious threat to your or anyone else’s health or safety; or to provide information for workers’ compensation purposesservices. Except as described abovein this notice, Sweetser other uses and disclosures will not use or disclose your health care information without your written authorization. Your written authorization will in any event be required for any use or disclosure of psychotherapy notes and for any use or disclosure of health care information which is for marketing purposes or which involves sale of your health care information. You may revoke any authorization at any time, in writing or verbally, by communicating the revocation to the clinician or caseworker principally responsible for your care or to a supervisor or manager within the program from which you receive services, or to a member of Xxxxxxxx’x Client Records Department staff. Revocation will not, however, be effective made only with regard to actions already taken in reliance on your authorization. Your privacy rights You may request restrictions on the use This can take place with authorization, such as at minimum a verbal permission or disclosure a signed Release of your health care information, but Sweetser is not required to agree to any requested restriction. It is Xxxxxxxx’x policy not to agree to such a restriction unless Sweetser determines, in its sole discretion, that there is compelling need for the restriction and the restriction can feasibly be implemented. Sweetser will, however, agree not to disclose your health care information to a health plan in order to obtain payment for services provided to you if Sweetser has received payment in full for the services from you or someone acting on your behalf. You may request that communications to you be given in a way which will help keep them confidential, for exampleInformation form, by using a particular address or telephone number to contact you. Sweetser Health information used or disclosed to other parties will comply with such a request if it is reasonable and feasible. To request restrictions or a confidential manner of communicating, you should submit a written request be limited to the clinician or caseworker principally responsible for your care, or to a supervisor or manager within the program from which you receive services, or to a member of Xxxxxxxx’x Client Records Department. You have the right: to receive an accounting of any disclosures of your health care information apart from ones which you authorized or which were made for treatment, payment or health care operations; to inspect and copy your health care information; to amend your health care information; and to receive a paper copy of this Notice of Privacy Practices. To exercise any of the above rights, please submit your request in writing to Xxxxxxxx’x Privacy Officer at the address below. You may also contact the Privacy Officer to obtain further information about Xxxxxxxx’x privacy policies and practices. “Minimum Necessary.” If you believe your privacy rights have been violatedwritten authorization is given, you may complain to Sweetser or to the Secretary of the U.S. Department of Health revoke your authorization, except when disclosures by myself have already been authorized and Human Services. To file a complaint with Sweetser, please submit your complaint in writing to Xxxxxxxx’x Compliance Officer at the address below. A complaint form will be supplied on request but is not required. Nobody is permitted to retaliate against you for filing a complaint. To exercise rights or obtain information: To file a complaint with Sweetser: Privacy Officer Compliance Officer Sweetser Sweetser 00 Xxxxx Xxxxxx 00 Xxxxx Xxxxxx Saco, ME 04072 Saco, ME 04072 (000) 000-0000made.

Notice of Privacy Practices. Health Information Portability and Accountability Act Effective April 14May 27, 2003, as revised September 1, 2013 2010 and Regulations on 42 C.F.R 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. Sweetser Xxxxx X Xxxxx is required by law to maintain the privacy of your health care information, information and to provide you with a notice of Xxxxxxxx’x legal duties and privacy practices with respect to your health care information and to notify affected individuals if there should be a breach of unsecured health information held by Sweetserpractices. Sweetser Xxxxx X Xxxxx is required to follow the terms of the privacy notice in effect at any particular time, but Sweetser reserves the right to change its privacy practices at any time. Any change will apply to all health care information maintained by Sweetser Xxxxx X Xxxxx and will be set forth in a new notice of privacy practices which will be available at your next visit following the change. At any time, you may obtain a copy of the notice of privacy practices currently in effect by requesting a copy in writing from Xxxxxxxx’x Privacy Officer Xxxxx X Xxxxx at the address specified below. Use and disclosure of your health care information Sweetser Xxxxx X Xxxxx may use your health care information for purposes of treatment, payment and health care operations. For example: Your information may be used to assess your needs and develop an individualized service plan or to coordinate a referral to another health care provider. Portions of your information may be submitted to a state agency, insurance carrier or other third-party payer to secure payment for services provided to you, unless you have arranged personally to pay in full all charges for services provided to you. Your information may be used for operations of Sweetser related to health care activities, such as quality assurance, evaluation, training, audits and administration. Sweetser Xxxxx X Xxxxx may use your health care information to contact you to remind you of an appointment or to provide information about treatment alternatives or other health services or about Sweetser and our programsservices. We may also use it to contact you for fundraising purposes, but if we do so, you have the right to choose not to receive subsequent fundraising communications and we will offer you the option to do so. Sweetser Xxxxx X Xxxxx may disclose your health care information to another person or entity performing services on Xxxxxxxx’x Xxxxx X Xxxxx’x behalf which relate to treatment, payment or health care operations and which require access to your information. That person or entity will have access to your information only to perform those services and must agree in writing to maintain the confidentiality of your information. Sweetser Xxxxx X Xxxxx may disclose your health care information without your authorization as permitted or required by applicable law, including any of the following: to comply with public health statutes and rules; to make any required reports of abuse or neglect; to comply with health care oversight activities of a government agency (such as licensing); to comply with a court order, search warrant or other lawful process; to allow approved research projects to be conducted; to provide information to a medical examiner in the event of your death; to avert a serious threat to your or anyone else’s health or safety; or to provide information for workers’ compensation purposes. Except as described above, Sweetser Xxxxx X Xxxxx will not use or disclose your health care information without information, except with your written authorization. Your written authorization will in any event be required for any use or disclosure of psychotherapy notes and for any use or disclosure of health care information which is for marketing purposes or which involves sale of your health care information. You may revoke any authorization at any time, in writing or verbally, by communicating the revocation to the clinician or caseworker principally responsible for your care or to a supervisor or manager within the program from which you receive services, or to a member of Xxxxxxxx’x Client Records Department staffXxxxx X Xxxxx. Revocation will not, however, be effective with regard to actions already taken in reliance on your authorization. Except in the case of gross negligence or malpractice, I or my representative(s) agree to full release and hold harmless Xxxxx X Xxxxx, PhD, LCPC from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with my session(s). Federal law and regulations do not protect any information: about a crime committed by you either on Xxxxx X Xxxxx’x premises or against any person who works for Xxxxx X Xxxxx or about a threat to commit such a crime; or about suspected child abuse or neglect required to be reported to state or local authorities under state law. (See 42 U.S.C. section 290dd-3 and 42 U.S.C. section 290ee-3 for Federal laws and 42 C.F.R. part 2 for Federal regulations.) Your privacy rights Privacy Rights You may request restrictions on the use or disclosure of your health care information, but Sweetser Xxxxx X Xxxxx is not required to agree to any requested restriction. It is Xxxxxxxx’x Xxxxx X Xxxxx’x policy not to agree to such a restriction unless Sweetser determinesit is determined, in its sole her discretion, that there is compelling need for the restriction and the restriction can feasibly be implemented. Sweetser will, however, agree not to disclose your health care information to a health plan in order to obtain payment for services provided to you if Sweetser has received payment in full for the services from you or someone acting on your behalf. You may request that communications to you be given in a way which will help keep them confidential, for example, by using a particular address or telephone number to contact you. Sweetser Xxxxx X Xxxxx will comply with such a request if it is reasonable and feasible. To request restrictions or a confidential manner of communicating, you should submit a written request to the clinician or caseworker principally responsible for your care, or to a supervisor or manager within the program from which you receive services, or to a member of Xxxxxxxx’x Client Records DepartmentXxxxx X Xxxxx. You have the right: to receive an accounting of any disclosures of your health care information apart from ones which you authorized or which were made for treatment, payment or health care operations; to inspect and copy your health care information; to amend your health care information; and to receive a paper copy of this Notice of Privacy Practices. To exercise any of the above rights, please submit your request in writing to Xxxxxxxx’x Privacy Officer at the address belowXxxxx X Xxxxx. You may also contact the Privacy Officer Xxxxx X Xxxxx to obtain further information about Xxxxxxxx’x privacy policies and practices. Violation of the federal law and regulations by an alcohol or drug abuse treatment program is a crime. If you suspect that Xxxxx X Xxxxx or anyone else has violated these laws, you may report the violation to appropriate authorities in accordance with federal regulations. If you believe your privacy rights have been violated, you may complain to Sweetser Xxxxx X Xxxxx or to the Secretary of the U.S. Department of Health and Human Services. To file a complaint with SweetserXxxxx X Xxxxx, please submit your complaint in writing to Xxxxxxxx’x Compliance Officer at the address below. A complaint form will be supplied on request but is not required. Nobody is permitted to retaliate against you for filing a complaint. To exercise rights or obtain information: To file a complaint with Sweetsercomplaint: Privacy Officer Compliance Officer Sweetser Sweetser Xxxxx X Xxxxx, PhD, LCPC Department of Professional and Financial Regulation 00 Xxxxx Xxxxxxxxx Xxxxxx 00 Xxxxx Xxxxxx Saco35 State House Station Xxxxxxxx, ME 04072 Saco04345 Augusta, ME 04072 (000) 04330 000-0000000-0000 000-000-0000 Client Name: DOB: Client No: Xxxxx X Xxxxx, PhD, LCPC AUTHORIZATION SIGNATURE PAGE My signature below indicates that I have read the preceding sections I, II and III, that I have been provided a copy of the documents noted below, and that I have/will have had an opportunity to discuss and ask questions about them with Xxxxx X Xxxxx. My signature below also indicates that I agree to have Xxxxx X Xxxxx provide services as described above in the Section I. Counseling Service Agreement and that I agree to the provisions within that section. This Service Agreement will be in effect and apply to counseling services, and will terminate only when I am discharged completely from all counseling services with Xxxxx X Xxxxx, PhD, LCPC.

Notice of Privacy Practices. Effective April 14, 2003, as revised September 1, 2013 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATIONThis Notice describes how health Information about you may be used and disclosed and how you can get access to this information. PLEASE REVIEW IT CAREFULLYPlease review it carefully. Sweetser The privacy of your health information is important to us. We are required by applicable federal and state law to maintain the privacy of your protected health care information. We are also required to give you this Notice about our privacy practices, to provide you with a notice of Xxxxxxxx’x our legal duties duties, and your rights concerning your protected health information. We must follow the privacy practices with respect to your health care information that are described in this Notice while it is in effect. This Notice takes effect January 31, 2012, and to notify affected individuals if there should be a breach of unsecured health information held by Sweetser. Sweetser is required to follow the terms of the privacy notice will remain in effect at any particular time, but Sweetser reserves until we replace it. We reserve the right to change its our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and provide the new Notice at our practice location, and we will distribute it upon request. You may request a copy of our Notice at any time. Any change will apply For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this notice. Your Authorization: In addition to all our use of your health care information maintained by Sweetser and will be set forth in a new notice of privacy practices which will be available at your next visit for the following the change. At any timepurposes, you may obtain a copy of the notice of privacy practices currently in effect by requesting a copy in writing from Xxxxxxxx’x Privacy Officer at the address specified below. Use and disclosure of your health care information Sweetser may give us written authorization to use your health care information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for purposes of any reason except those described in this Notice. USES AND DISCLOSURES OF HEALTH INFORMATION -We use and disclose health information about you without authorization for the following purposes: Treatment: We may use or disclose your health information for your treatment. For example, we may disclose your health information to a physician or other healthcare provider providing treatment to you. Payment: We may use or disclose your health information to obtain payment and for services we provide to you. For example, we may send claims to your dental health plan containing certain health information. Healthcare Operations: We may use or disclose your health information in connection with our health care operations. For example, healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities. To You or Your Personal Representative: Your We must disclose your health information may be used to assess your needs and develop an individualized service plan or to coordinate a referral to another health care provider. Portions of your information may be submitted to a state agency, insurance carrier or other third-party payer to secure payment for services provided to you, unless you have arranged personally to pay as described in full all charges for services provided to you. Your information may be used for operations the Patient Rights section of Sweetser related to health care activities, such as quality assurance, evaluation, training, audits and administration. Sweetser may use your health care information to contact you to remind you of an appointment or to provide information about treatment alternatives or other health services or about Sweetser and our programsthis Notice. We may also use it to contact you for fundraising purposes, but if we do so, you have the right to choose not to receive subsequent fundraising communications and we will offer you the option to do so. Sweetser may disclose your health care information to another person or entity performing services on Xxxxxxxx’x behalf which relate to treatmentyour personal representative, payment or health care operations and which require access to your informationbut only if you agree that we may do so. That person or entity will have access to your information only to perform those services and must agree Persons Involved in writing to maintain the confidentiality of your information. Sweetser Care: We may disclose your health care information without your authorization as permitted or required by applicable law, including any of the following: to comply with public health statutes and rules; to make any required reports of abuse or neglect; to comply with health care oversight activities of a government agency (such as licensing); to comply with a court order, search warrant or other lawful process; to allow approved research projects to be conducted; to provide information to a medical examiner in the event of your death; to avert a serious threat to your or anyone else’s health or safety; or to provide information for workers’ compensation purposes. Except as described above, Sweetser will not use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your health care information without your written authorization. Your written authorization will in any event be required for any use personal representative or disclosure of psychotherapy notes and for any use or disclosure of health care information which is for marketing purposes or which involves sale of your health care information. You may revoke any authorization at any time, in writing or verbally, by communicating the revocation to the clinician or caseworker principally another person responsible for your care or to a supervisor or manager within the program from which you receive servicescare, of your location, your general condition, or death. If you are present, then prior to a member of Xxxxxxxx’x Client Records Department staff. Revocation will not, however, be effective with regard to actions already taken in reliance on your authorization. Your privacy rights You may request restrictions on the use or disclosure of your health care information, but Sweetser is not required we will provide you with an opportunity to agree to any requested restriction. It is Xxxxxxxx’x policy not to agree object to such uses or disclosures. In the event of your absence or incapacity or in emergency circumstances, we will disclose health information based on a restriction unless Sweetser determinesdetermination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, in its sole discretionmedical supplies, that there is compelling need for the restriction and the restriction can feasibly be implementedx-rays, or other similar forms of health information. Sweetser will, however, agree not to Disaster Relief: We may use or disclose your health care information to a health plan assist in order to obtain payment for services provided to you if Sweetser has received payment in full for the services from you or someone acting on your behalfdisaster relief efforts. You may request that communications to you be given in a way which Marketing Health Related Services: We will help keep them confidential, for example, by using a particular address or telephone number to contact you. Sweetser will comply with such a request if it is reasonable and feasible. To request restrictions or a confidential manner of communicating, you should submit a written request to the clinician or caseworker principally responsible for your care, or to a supervisor or manager within the program from which you receive services, or to a member of Xxxxxxxx’x Client Records Department. You have the right: to receive an accounting of any disclosures of not use your health care information apart from ones which you authorized or which were made for treatment, payment or health care operations; to inspect and copy marketing communications without your health care information; to amend your health care information; and to receive a paper copy of this Notice of Privacy Practices. To exercise any of the above rights, please submit your request in writing to Xxxxxxxx’x Privacy Officer at the address below. You may also contact the Privacy Officer to obtain further information about Xxxxxxxx’x privacy policies and practices. If you believe your privacy rights have been violated, you may complain to Sweetser or to the Secretary of the U.S. Department of Health and Human Services. To file a complaint with Sweetser, please submit your complaint in writing to Xxxxxxxx’x Compliance Officer at the address below. A complaint form will be supplied on request but is not required. Nobody is permitted to retaliate against you for filing a complaint. To exercise rights or obtain information: To file a complaint with Sweetser: Privacy Officer Compliance Officer Sweetser Sweetser 00 Xxxxx Xxxxxx 00 Xxxxx Xxxxxx Saco, ME 04072 Saco, ME 04072 (000) 000-0000written authorization.

Notice of Privacy Practices. Effective April 14, 2003, as revised September 1, 2013 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. Sweetser is required by law to maintain the privacy of your health care information, to provide you with a notice of Xxxxxxxx’x legal duties and privacy practices with respect to your health care information and to notify affected individuals if there should be a breach of unsecured health information held by Sweetser. Sweetser is required to follow the terms of the privacy notice in effect at any particular time, but Sweetser reserves the right to change its privacy practices at any time. Any change will apply to all health care information maintained by Sweetser and will be set forth in a new notice of privacy practices which will be available at your next visit following the change. At any time, you may obtain a copy of the notice of privacy practices currently in effect by requesting a copy in writing from Xxxxxxxx’x Privacy Officer at the address specified below. Use and disclosure of your health care information Sweetser may use your health care information for purposes of treatment, payment and health care operations. For example: Your information may be used to assess your needs and develop an individualized service plan or to coordinate a referral to another health care provider. Portions of your information may be submitted to a state agency, insurance carrier or other third-party payer to secure payment for services provided to you, unless you have arranged personally to pay in full all charges for services provided to you. Your information may be used for operations of Sweetser related to health care activities, such as quality assurance, evaluation, training, audits and administration. Sweetser may use your health care information to contact you to remind you of an appointment or to provide information about treatment alternatives or other health services or about Sweetser and our programs. We may also use it to contact you for fundraising purposes, but if we do so, you have the right to choose not to receive subsequent fundraising communications and we will offer you the option to do so. Sweetser may disclose your health care information to another person or entity performing services on Xxxxxxxx’x behalf which relate to treatment, payment or health care operations and which require access to your information. That person or entity will have access to your information only to perform those services and must agree in writing to maintain the confidentiality of your information. Sweetser may disclose your health care information without your authorization as permitted or required by applicable law, including any of the following: to comply with public health statutes and rules; to make any required reports of abuse or neglect; to comply with health care oversight activities of a government agency (such as licensing); to comply with a court order, search warrant or other lawful process; to allow approved research projects to be conducted; to provide information to a medical examiner in the event of your death; to avert a serious threat to your or anyone else’s health or safety; or to provide information for workers’ compensation purposes. Except as described above, Sweetser will not use or disclose your health care information without your written authorization. Your written authorization will in any event be required for any use or disclosure of psychotherapy notes and for any use or disclosure of health care information which is for marketing purposes or which involves sale of your health care information. You may revoke any authorization at any time, in writing or verbally, by communicating the revocation to the clinician or caseworker principally responsible for your care or to a supervisor or manager within the program from which you receive services, or to a member of Xxxxxxxx’x Client Records Department staff. Revocation will not, however, be effective with regard to actions already taken in reliance on your authorization. Your privacy rights You may request restrictions on the use or disclosure of your health care information, but Sweetser is not required to agree to any requested restriction. It is Xxxxxxxx’x policy not to agree to such a restriction unless Sweetser determines, in its sole discretion, that there is compelling need for the restriction and the restriction can feasibly be implemented. Sweetser will, however, agree not to disclose your health care information to a health plan in order to obtain payment for services provided to you if Sweetser has received payment in full for the services from you or someone acting on your behalf. You may request that communications to you be given in a way which will help keep them confidential, for example, by using a particular address or telephone number to contact you. Sweetser will comply with such a request if it is reasonable and feasible. To request restrictions or a confidential manner of communicating, you should submit a written request to the clinician or caseworker principally responsible for your care, or to a supervisor or manager within the program from which you receive services, or to a member of Xxxxxxxx’x Client Records DepartmentDepartment staff. You have the right: to receive an accounting of any disclosures of your health care information apart from ones which you authorized or which were made for treatment, payment or health care operations; to inspect and copy your health care information; to amend your health care information; and to receive a paper copy of this Notice of Privacy Practices. To exercise any of the above rights, please submit your request in writing to Xxxxxxxx’x Privacy Officer at the address below. You may also contact the Privacy Officer to obtain further information about Xxxxxxxx’x privacy policies and practices. If you believe your privacy rights have been violated, you may complain to Sweetser or to the Secretary of the U.S. Department of Health and Human Services. To file a complaint with Sweetser, please submit your complaint in writing to Xxxxxxxx’x Compliance Officer at the address below. A complaint form will be supplied on request but is not required. Nobody is permitted to retaliate against you for filing a complaint. To exercise rights or obtain information: To file a complaint with Sweetser: Privacy Officer Compliance Officer Sweetser Sweetser 00 Xxxxx Xxxxxx 00 Xxxxx Xxxxxx Saco, ME 04072 Saco, ME 04072 (000) 000-0000

Notice of Privacy Practices. Effective Following is the StarCare policy regarding the Notice of Privacy Practices which was developed April 14, 2003: Notice of Privacy Practices: This notice gives you information about the type of data we collect and keep how we protect that data and to whom and under what circumstances we may release that data. Because you receive services from Silver Star, as revised September 1the agency collects and maintains information about you. That information includes: Your past, 2013 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATIONpresent or future physical or mental health or condition; The care and services provided to you; and Past, present and future payments charged for your care and services. PLEASE REVIEW IT CAREFULLYThe following notice tells you about the responsibility of Silver Star to protect your information, your privacy rights and how the Silver Star may use or disclose this information. Sweetser Silver Star Duties: Silver Star is required by law to maintain the privacy of protect your health care information, to provide you with a notice of Xxxxxxxx’x legal duties and privacy practices with respect to your health care information and to notify affected individuals if there should be a breach of unsecured health information held by Sweetser. Sweetser is required to follow the terms of the privacy notice in effect at any particular time, but Sweetser reserves the right to change its privacy practices at any time. Any change will apply to all health care information maintained by Sweetser and will be set forth in a new notice of privacy practices which will be available at your next visit following the change. At any time, you may obtain a copy of the notice of privacy practices currently in effect by requesting a copy in writing from Xxxxxxxx’x Privacy Officer at the address specified below. Use and disclosure of your health care information Sweetser may use your health care information for purposes of treatment, payment and health care operations. For example: Your information may be used to assess your needs and develop an individualized service plan or to coordinate a referral to another health care provider. Portions of your information may be submitted to a state agency, insurance carrier or other third-party payer to secure payment for services provided to you, unless you have arranged personally to pay in full all charges for services provided to you. Your information may be used for operations of Sweetser related to health care activities, such as quality assurance, evaluation, training, audits and administration. Sweetser may use your health care information to contact you to remind you of an appointment or to provide information about treatment alternatives or other health services or about Sweetser and our programs. We may also use it to contact you for fundraising purposes, but if we do so, you have the right to choose not to receive subsequent fundraising communications and we will offer you the option to do so. Sweetser may disclose your health care information to another person or entity performing services on Xxxxxxxx’x behalf which relate to treatment, payment or health care operations and which require access to your information. That person or entity will have access to your information only to perform those services and must agree in writing to maintain the confidentiality of your information. Sweetser may disclose your health care information without your authorization as permitted or required by applicable law, including any of the following: to comply with public health statutes and rules; to make any required reports of abuse or neglect; to comply with health care oversight activities of a government agency (such as licensing); to comply with a court order, search warrant or other lawful process; to allow approved research projects to be conducted; to provide information to a medical examiner in the event of your death; to avert a serious threat to your or anyone else’s health or safety; or to provide information for workers’ compensation purposes. Except as described above, Sweetser This means that Silver Star will not use or disclose your health care information without your permission, with some exceptions, which we will outline in this notice. All health information about you will be kept private no matter when you received services. Silver Star will not allow anyone to film, photograph, interview, or record you without your written authorizationpermission. Your We will not tell anyone if you are receiving services or may have received services in the past. If Silver Star receives a legally authorized directive to disclose your health information, we will only disclose the information necessary to meet the request and where possible we will de-identify your protected health information prior to release. Silver Star will ask for your written authorization will in any event be required for any permission to use or disclosure of psychotherapy notes disclose your health information unless we are permitted to use or disclose your health information without your permission as outlined in this notice. If you have given us your permission to use or disclose your health information and you want to revoke that permission you may do so at any time by contacting your Silver Star social worker. However, you cannot hold us liable for any use or disclosure of health care information which prior to the revocation. Silver Star is for marketing purposes or which involves sale required to give you this notice that outlines our duties and privacy practices and be able to verify through your signature on the attached page that you have received this information. If Silver Star changes any of its privacy practices we have to notify you of those changes. Silver Star staff, as a condition of their employment, must protect the privacy of your health care information. You may revoke any authorization at any time, in writing or verbally, by communicating Silver Star staff will share information about you on a need to know basis. Staff `will encounter serious consequences if they do not protect the revocation to the clinician or caseworker principally responsible for your care or to a supervisor or manager within the program from which you receive services, or to a member of Xxxxxxxx’x Client Records Department staff. Revocation will not, however, be effective with regard to actions already taken in reliance on your authorization. Your privacy rights You may request restrictions on the use or disclosure of your health care information, but Sweetser is not required to agree to any requested restriction. It is Xxxxxxxx’x policy not to agree to such a restriction unless Sweetser determines, in its sole discretion, that there is compelling need for the restriction and the restriction can feasibly be implemented. Sweetser will, however, agree not to disclose your health care information to a health plan in order to obtain payment for services provided to you if Sweetser has received payment in full for the services from you or someone acting on your behalf. You may request that communications to you be given in a way which will help keep them confidential, for example, by using a particular address or telephone number to contact you. Sweetser will comply with such a request if it is reasonable and feasible. To request restrictions or a confidential manner of communicating, you should submit a written request to the clinician or caseworker principally responsible for your care, or to a supervisor or manager within the program from which you receive services, or to a member of Xxxxxxxx’x Client Records Department. You have the right: to receive an accounting of any disclosures of your health care information apart from ones which you authorized or which were made for treatment, payment or health care operations; to inspect and copy your health care information; to amend your health care information; and to receive a paper copy of this Notice of Privacy Practices. To exercise any of the above rights, please submit your request in writing to Xxxxxxxx’x Privacy Officer at the address below. You may also contact the Privacy Officer to obtain further information about Xxxxxxxx’x privacy policies and practices. If you believe are receiving treatment for chemical dependency (drug/alcohol) your privacy rights records are protected by a federal law. (Code of Federal Regulations, Title 2, Part 2) Violations of those laws are a crime and suspected violations may be reported to appropriate authorities. Federal law does not protect any information about a crime, which a person may have committed against an employee of Silver Star or a threat made against an employee of Silver Star. Federal laws also do not protect any information about suspected child abuse or neglect, which has been violated, you may complain reported under State law to Sweetser or to the Secretary appropriate State of the U.S. Department of Health and Human Services. To file a complaint with Sweetser, please submit your complaint in writing to Xxxxxxxx’x Compliance Officer at the address below. A complaint form will be supplied on request but is not required. Nobody is permitted to retaliate against you for filing a complaint. To exercise rights or obtain information: To file a complaint with Sweetser: Privacy Officer Compliance Officer Sweetser Sweetser 00 Xxxxx Xxxxxx 00 Xxxxx Xxxxxx Saco, ME 04072 Saco, ME 04072 (000) 000-0000local authorities.

Notice of Privacy Practices. Effective April 14, 2003, as revised September 1, 2013 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATIONThis notice describes how medical information about you may be used and disclosed and how you can get access to this information. PLEASE REVIEW IT CAREFULLYWe hope this provides a helpful orientation and makes your subsequent visits much faster and more enjoyable. Sweetser is required by law We appreciate you being a member of OC Sports & Wellness and look forward to maintain assisting you in the privacy optimization of your health. Patient Partnership Agreement Achieving your best possible health care informationrequires a partnership between you and your physician. As “partners in health,” we want to encourage you to work with us in the following ways: Take a proactive role in your health. I understand that I am responsible for my health and that I am entering into this partnership to help achieve the best possible health for me. My physician will make recommendations regarding certain health screenings during my annual health exam appropriate for my age, gender, and personal and family history. I understand I will need to complete these recommended health screenings (mammogram, immunizations, pap smears, etc.) in order to optimize my health and detect any potentially serious health conditions. I understand that if I don’t complete these screenings I place myself at risk. Keep follow up appointments and reschedule missed appointments. I understand that my physician will want to know how my health changes after my appointment and throughout the year. Regular visits with my physician provide you with opportunities for ongoing assessments of my health. During these appointments, my physician might order tests, refer me to specialists, prescribe medication, or manage a notice serious health condition. If I miss an appointment, I run the risk that my physician will not be able to assist in optimizing my health. Also, I will make every effort to reschedule missed appointments. Call the office when I do not hear the results of Xxxxxxxx’x legal duties and privacy practices with respect any diagnostic tests. I understand that my physician’s goal is to your health care information and report all my diagnostic test results to notify affected individuals me as soon as possible. However, if there should be a breach of unsecured health information held by SweetserI do not hear from my physician’s office within the time specified, I will call the office for my results. Sweetser is required Inform my doctor if I choose not to follow the terms of the privacy notice in effect at any particular timerecommended treatment plan. I understand that after examining me, but Sweetser reserves the right to change its privacy practices at any timemy physician may make certain recommendations based on his or her assessment. Any change will apply to all health care information maintained by Sweetser and will be set forth in a new notice of privacy practices which will be available at your next visit following the change. At any timeThis might include prescribing medication, you may obtain a copy of the notice of privacy practices currently in effect by requesting a copy in writing from Xxxxxxxx’x Privacy Officer at the address specified below. Use and disclosure of your health care information Sweetser may use your health care information for purposes of treatment, payment and health care operations. For example: Your information may be used to assess your needs and develop an individualized service plan or to coordinate a referral to another health care provider. Portions of your information may be submitted referring me to a state agencyspecialist, insurance carrier ordering diagnostic tests, or other third-party payer even asking me to secure payment for services provided return to you, unless you the office within a certain time period. I understand that not following my treatment plan can have arranged personally serious negative effects on my health. I will inform my physician whenever I decide not to pay in full all charges for services provided follow recommendations so that my physician may fully inform me of any risks associated with my decision to younot follow treatment plan recommendations. Your information may be used for operations of Sweetser related to health care activities, such as quality assurance, evaluation, training, audits and administration. Sweetser may use your health care information to contact you to remind you of an appointment or to provide information about treatment alternatives or other health services or about Sweetser and our programs. We may also use it to contact Thank you for fundraising purposes, but if we do soyou agreeing to partner together with us on your health. As our patient, you have the right to choose not to receive subsequent fundraising communications and we will offer you the option to do so. Sweetser may disclose be informed about your health care information to another person or entity performing services on Xxxxxxxx’x behalf which relate to treatmentcare. We invite you, payment or health care operations and which require access to your information. That person or entity will have access to your information only to perform those services and must agree in writing to maintain the confidentiality of your information. Sweetser may disclose your health care information without your authorization as permitted or required by applicable law, including any of the following: to comply with public health statutes and rules; to make any required reports of abuse or neglect; to comply with health care oversight activities of a government agency (such as licensing); to comply with a court order, search warrant or other lawful process; to allow approved research projects to be conducted; to provide information to a medical examiner in the event of your death; to avert a serious threat to your or anyone else’s health or safety; or to provide information for workers’ compensation purposes. Except as described above, Sweetser will not use or disclose your health care information without your written authorization. Your written authorization will in any event be required for any use or disclosure of psychotherapy notes and for any use or disclosure of health care information which is for marketing purposes or which involves sale of your health care information. You may revoke any authorization at any time, in writing or verballyto ask questions, by communicating the revocation to the clinician or caseworker principally responsible for your care or to a supervisor or manager within the program from which you receive servicesreport symptoms, or to a member of Xxxxxxxx’x Client Records Department staff. Revocation will not, however, be effective with regard to actions already taken in reliance on your authorization. Your privacy rights You discuss any concerns you may request restrictions on the use or disclosure of your health care information, but Sweetser is not required to agree to any requested restriction. It is Xxxxxxxx’x policy not to agree to such a restriction unless Sweetser determines, in its sole discretion, that there is compelling need for the restriction and the restriction can feasibly be implemented. Sweetser will, however, agree not to disclose your health care information to a health plan in order to obtain payment for services provided to you if Sweetser has received payment in full for the services from you or someone acting on your behalf. You may request that communications to you be given in a way which will help keep them confidential, for example, by using a particular address or telephone number to contact you. Sweetser will comply with such a request if it is reasonable and feasible. To request restrictions or a confidential manner of communicating, you should submit a written request to the clinician or caseworker principally responsible for your care, or to a supervisor or manager within the program from which you receive services, or to a member of Xxxxxxxx’x Client Records Department. You have the right: to receive an accounting of any disclosures of your health care information apart from ones which you authorized or which were made for treatment, payment or health care operations; to inspect and copy your health care information; to amend your health care information; and to receive a paper copy of this Notice of Privacy Practices. To exercise any of the above rights, please submit your request in writing to Xxxxxxxx’x Privacy Officer at the address below. You may also contact the Privacy Officer to obtain further information about Xxxxxxxx’x privacy policies and practiceshave. If you believe need more information about your privacy rights have been violated, you may complain to Sweetser health or to the Secretary of the U.S. Department of Health and Human Services. To file a complaint with Sweetsercondition, please submit your complaint in writing do not hesitate to Xxxxxxxx’x Compliance Officer at ask. Patient Signature Date Registration Form PATIENT INFORMATION Last Name First Middle Marital Status Single / Mar/ Div / Partner / Widow Street Address City State Zip Birthdate Sex Social Security # M F Email Address ( to sign up for the address below. A complaint form will be supplied on request but is not required. Nobody is permitted to retaliate against you for filing a complaint. To exercise rights or obtain informationpatient portal) Occupation Home Phone Cell Phone Work Phone ( ) ( ) ( ) If Minor, Legal Guardian: To file a complaint with Sweetser: Privacy Officer Compliance Officer Sweetser Sweetser 00 Xxxxx Xxxxxx 00 Xxxxx Xxxxxx Saco, ME 04072 Saco, ME 04072 (000) 000-0000Guardian Phone

Notice of Privacy Practices. Effective April 14, 2003, as revised September 1, 2013 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATIONThis section describes how health information about you may be used and disclosed and how you can get access to this information. PLEASE REVIEW IT CAREFULLYPlease review it carefully. Sweetser The privacy of your health information is important to us. Confidentiality of your health care information This notice is required by law to maintain inform you of how Delta Dental protects the privacy confidentiality of your health care informationinformation in our possession. Protected Health Information (PHI) is defined as individually identifiable information regarding a patient's health care history, mental or physical condition or treatment. Some examples of PHI include your name, address, telephone and/or fax number, electronic mail address, social security number or other identification number, date of birth, date of treatment, treatment records, x-rays, enrollment and claims records. Delta Dental receives, uses and discloses your PHI to provide you with a notice administer your benefit plan or as permitted or required by law. Any other disclosure of Xxxxxxxx’x legal duties and your PHI without your authorization is prohibited. We follow the privacy practices with respect described in this notice and federal and state privacy requirements that apply to our administration of your health care information and to notify affected individuals if there should be a breach of unsecured health information held by Sweetserbenefits. Sweetser is required to follow the terms of the privacy notice in effect at any particular time, but Sweetser Delta Dental reserves the right to change its our privacy practices practice effective for all PHI maintained. We will update this notice if there are material changes and redistribute it to you within 60 days of the change to our practices. We will also promptly post a revised notice on our website. A copy may be requested anytime by contacting the address or phone number at any timethe end of this notice. Any change will apply to all health care information maintained by Sweetser You should receive a copy of this notice at the time of enrollment in a Delta Dental program and will be set forth in a new notice of privacy practices which will be available at your next visit following the change. At any time, you may informed on how to obtain a copy of the notice of privacy practices currently in effect by requesting a copy in writing from Xxxxxxxx’x Privacy Officer at the address specified belowleast every three years. Use Permitted uses and disclosure disclosures of your health care information Sweetser may use your health care information for purposes of treatment, payment PHI Uses and health care operations. For example: Your information may be used to assess your needs and develop an individualized service plan or to coordinate a referral to another health care provider. Portions disclosures of your information may be submitted to a state agency, insurance carrier or other third-party payer to secure payment PHI for services provided to you, unless you have arranged personally to pay in full all charges for services provided to you. Your information may be used for operations of Sweetser related to health care activities, such as quality assurance, evaluation, training, audits and administration. Sweetser may use your health care information to contact you to remind you of an appointment or to provide information about treatment alternatives or other health services or about Sweetser and our programs. We may also use it to contact you for fundraising purposes, but if we do so, you have the right to choose not to receive subsequent fundraising communications and we will offer you the option to do so. Sweetser may disclose your health care information to another person or entity performing services on Xxxxxxxx’x behalf which relate to treatment, payment or health care operations Your explicit authorization is not required to disclose information about yourself, or for purposes of health care treatment, payment of claims, billing of premiums, and which require access other health care operations. If your benefit plan is sponsored by your employer or another party, we may provide PHI to your informationemployer or plan sponsor to administer your benefits. That person or entity will As permitted by law, we may also disclose PHI to third party affiliates that perform services for Delta Dental to administer your benefits. As permitted by law, we may disclose PHI to third-party affiliates that perform services for Delta Dental to administer your benefits, and who have access signed a contract agreeing to your information only to perform those services and must agree in writing to maintain protect the confidentiality of your informationPHI, and have implemented privacy policies and procedures that comply with applicable federal and state law. Sweetser Some examples of disclosure and use for treatment, payment or operations include: processing your claims, collecting enrollment information and premiums, reviewing the quality of health care you receive, providing customer service, resolving your grievances, and sharing payment information with other insurers. Some other examples are: • Uses and/or disclosures of PHI in facilitating treatment. For example, Delta Dental may use or disclose your PHI to determine eligibility for services requested by your provider. • Uses and/or disclosures of PHI for payment. For example, Delta Dental may use and disclose your PHI to bill you or your plan sponsor. • Uses and/or disclosures of PHI for health care operations. For example, Delta Dental may use and disclose your PHI to review the quality of care provided by our network of providers. Other permitted uses and disclosures without an authorization We are permitted to disclose your PHI upon your request or to your authorized personal representative (with certain exceptions) when required by the U. S. Secretary of Health and Human Services to investigate or determine our compliance with law, and when otherwise required by law. Delta Dental may disclose your health care information PHI without your prior authorization as permitted or required by applicable law, including any of in response to the following: • Court order; • Order of a board, commission, or administrative agency for purposes of adjudication pursuant to comply with public health statutes and rulesits lawful authority; to make any required reports of abuse or neglect• Subpoena in a civil action; to comply with health care oversight activities • Investigative subpoena of a government agency (such as licensing)board, commission, or agency; • Subpoena in an arbitration; • Law enforcement search warrant; or • Coroner's request during investigations. Some other examples include: to notify or assist in notifying a family member, another person, or a personal representative of your condition; to comply with a court order, search warrant or other lawful processassist in disaster relief efforts; to allow approved research projects report victims of abuse, neglect or domestic violence to be conductedappropriate authorities; to provide information to a medical examiner in the event of your deathfor organ donation purposes; to avert a serious threat to your or anyone else’s health or safety; or to provide information for specialized government functions such as military and veterans activities; for workers’ ' compensation purposes; and, with certain restrictions, we are permitted to use and/or disclose your PHI for underwriting, provided it does not contain genetic information. Except as described aboveInformation can also be de-identified or summarized so it cannot be traced to you and, Sweetser in selected instances, for research purposes with the proper oversight. Disclosures Delta Dental makes with your authorization Delta Dental will not use or disclose your health care information PHI without your written authorization. Your prior written authorization will in any event be required for any use or disclosure of psychotherapy notes and for any use or disclosure of health care information which is for marketing purposes or which involves sale of your health care informationunless permitted by law. You may can later revoke any authorization at any timethat authorization, in writing or verballywriting, by communicating to stop the revocation to the clinician or caseworker principally responsible for your care or to a supervisor or manager within the program from which you receive services, or to a member of Xxxxxxxx’x Client Records Department stafffuture use and disclosure. Revocation The authorization will not, however, be effective with regard to actions already taken in reliance on your authorization. Your privacy rights You may request restrictions on the use or disclosure of your health care information, but Sweetser is not required to agree to any requested restriction. It is Xxxxxxxx’x policy not to agree to such a restriction unless Sweetser determines, in its sole discretion, that there is compelling need for the restriction and the restriction can feasibly be implemented. Sweetser will, however, agree not to disclose your health care information to a health plan in order to obtain payment for services provided to you if Sweetser has received payment in full for the services obtained from you by Delta Dental or someone acting on by a person requesting your behalf. You may request that communications to you be given in a way which will help keep them confidential, for example, by using a particular address or telephone number to contact you. Sweetser will comply with such a request if it is reasonable and feasible. To request restrictions or a confidential manner of communicating, you should submit a written request to the clinician or caseworker principally responsible for your care, or to a supervisor or manager within the program PHI from which you receive services, or to a member of Xxxxxxxx’x Client Records Department. You have the right: to receive an accounting of any disclosures of your health care information apart from ones which you authorized or which were made for treatment, payment or health care operations; to inspect and copy your health care information; to amend your health care information; and to receive a paper copy of this Notice of Privacy Practices. To exercise any of the above rights, please submit your request in writing to Xxxxxxxx’x Privacy Officer at the address below. You may also contact the Privacy Officer to obtain further information about Xxxxxxxx’x privacy policies and practices. If you believe your privacy rights have been violated, you may complain to Sweetser or to the Secretary of the U.S. Department of Health and Human Services. To file a complaint with Sweetser, please submit your complaint in writing to Xxxxxxxx’x Compliance Officer at the address below. A complaint form will be supplied on request but is not required. Nobody is permitted to retaliate against you for filing a complaint. To exercise rights or obtain information: To file a complaint with Sweetser: Privacy Officer Compliance Officer Sweetser Sweetser 00 Xxxxx Xxxxxx 00 Xxxxx Xxxxxx Saco, ME 04072 Saco, ME 04072 (000) 000-0000Delta Dental.

Notice of Privacy Practices. Effective April 14Women’s Health Associates of Southern Nevada Las Vegas, 2003, as revised September 1, 2013 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. Sweetser is required by law NV to maintain the privacy of your health care information, to provide send you with a notice of Xxxxxxxx’x legal duties and privacy practices with respect to your health care information and to notify affected individuals if there should be a breach of unsecured health information held by Sweetser. Sweetser is required to follow the terms of the privacy notice in effect at any particular time, but Sweetser reserves the right to change its privacy practices at any time. Any change will apply to all health care information maintained by Sweetser and will be set forth in a new notice of privacy practices which will be available at your next visit following the change. At any time, you may obtain a copy of the notice of privacy practices currently in effect by requesting a copy in writing from Xxxxxxxx’x Privacy Officer at the address specified below. Use and disclosure of your health care information Sweetser may use your health care information for purposes of treatment, payment and health care operations. For example: Your information may be used to assess your needs and develop an individualized service plan appointment reminders or to coordinate a referral to another health care provider. Portions of your information may be submitted to a state agency, insurance carrier or other third-party payer to secure payment for services provided to you, unless you have arranged personally to pay in full all charges for services provided to you. Your information may be used for operations of Sweetser related to health care activities, such as quality assurance, evaluation, training, audits and administration. Sweetser may use your health care information to contact you to remind you of an appointment or to provide information about treatment alternatives or other health services related benefits that may be of interest to you. For example, we may look at your medical record to determine the date and time of your next appointment with us, and then send you a reminder to help you remember. Or, we may look at your medical information and decide that another treatment or about Sweetser and our programsa new service we offer may interest you. We may also use it to contact you and/or disclose your medical information in accordance with federal and state laws for fundraising the following purposes, but if we do so, you have the right to choose not to receive subsequent fundraising communications and we will offer you the option to do so. Sweetser : • We may disclose your health care medical information to another person law enforcement or entity performing services on Xxxxxxxx’x behalf which relate other specialized government functions in response to treatment, payment or health care operations and which require access to your information. That person or entity will have access to your information only to perform those services and must agree in writing to maintain the confidentiality of your information. Sweetser may disclose your health care information without your authorization as permitted or required by applicable law, including any of the following: to comply with public health statutes and rules; to make any required reports of abuse or neglect; to comply with health care oversight activities of a government agency (such as licensing); to comply with a court order, search warrant subpoena, warrant, summons, or other lawful similar process; . • We may disclose medical information when a law requires that we report information about suspected abuse, neglect or domestic violence, or relating to allow approved research projects suspected criminal activity, or in response to be conducted; to provide a court order. We must also disclose medical information to a authorities who monitor compliance with these privacy requirements. • We may disclose medical examiner in information when we are required to collect information about disease or injury, or to report vital statistics to the event public health authority. We may also disclose medical information to the protection and advocacy agency, or another agency responsible for monitoring the health care system for such purposes as reporting or investigation of your death; unusual incidents. • We may disclose medical information relating to avert an individual’s death to coroners, medical examiners or funeral directors, and to organ procurement organizations relating to organ, eye, or tissue donations or transplants. • In certain circumstances, we may disclose medical information to assist medical/psychiatric research. • In order to avoid a serious threat to your or anyone else’s health or safety; , we may disclose medical information to law enforcement or other persons who can reasonably prevent or lessen the threat of harm, or to provide information for workers’ compensation purposeshelp with the coordination of disaster relief efforts. Except • If people such as described abovefamily members, Sweetser will not use relatives, or disclose your health care information without your written authorization. Your written authorization will close personal friends are involved in any event be required for any use or disclosure of psychotherapy notes and for any use or disclosure of health care information which is for marketing purposes or which involves sale of your health care information. You may revoke any authorization at any time, in writing or verbally, by communicating the revocation to the clinician or caseworker principally responsible for your care or to a supervisor or manager within the program from which helping you receive servicespay your medical bills, we may release important health information about your location, general condition, or to a member of Xxxxxxxx’x Client Records Department staffdeath. Revocation will not, however, be effective with regard to actions already taken in reliance on your authorization. Your privacy rights You • We may request restrictions on the use or disclosure of your health care information, but Sweetser is not required to agree to any requested restriction. It is Xxxxxxxx’x policy not to agree to such a restriction unless Sweetser determines, in its sole discretion, that there is compelling need for the restriction and the restriction can feasibly be implemented. Sweetser will, however, agree not to disclose your health care medical information as authorized by law relating to a health plan worker’s compensation or similar programs. • We may disclose your medical information in order to obtain payment for services provided to you if Sweetser has received payment in full for the services from you course of certain judicial or someone acting on your behalfadministrative proceedings. You may request that communications to you be given in a way which will help keep them confidential, for example, by using a particular address or telephone number to contact you. Sweetser will comply with such a request if it is reasonable Other uses and feasible. To request restrictions or a confidential manner of communicating, you should submit a written request to the clinician or caseworker principally responsible for your care, or to a supervisor or manager within the program from which you receive services, or to a member of Xxxxxxxx’x Client Records Department. You have the right: to receive an accounting of any disclosures of your health care information apart from ones which you authorized or which were made for treatment, payment or health care operations; to inspect and copy medical information: State Health Information Exchange: We may make your health care information; information available electronically to amend other healthcare providers outside of our facility who are involved in your health care information; and to receive a paper copy of this Notice of Privacy Practices. To exercise any of the above rights, please submit your request in writing to Xxxxxxxx’x Privacy Officer at the address below. You may also contact the Privacy Officer to obtain further information about Xxxxxxxx’x privacy policies and practices. If you believe your privacy rights have been violated, you may complain to Sweetser or to the Secretary of the U.S. Department of Health and Human Services. To file a complaint with Sweetser, please submit your complaint in writing to Xxxxxxxx’x Compliance Officer at the address below. A complaint form will be supplied on request but is not required. Nobody is permitted to retaliate against you for filing a complaint. To exercise rights or obtain information: To file a complaint with Sweetser: Privacy Officer Compliance Officer Sweetser Sweetser 00 Xxxxx Xxxxxx 00 Xxxxx Xxxxxx Saco, ME 04072 Saco, ME 04072 (000) 000-0000care.