Common use of Your Choices Clause in Contracts

Your Choices. For certain service information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to: • Share information with your family, close friends, or others involved in your care • Share information in a disaster relief situation We may also share your information when needed to lessen a serious and imminent threat to health or safety. In these cases, we never share your information unless you give us written permission: • Marketing purposes • Sale of your information Our Uses and Disclosures Serve you We are allowed or required to share your information in other ways – usually in ways that coordinate your services with the contracted or governing government agencies. Run our organization We are allowed or required to share some Participant Employer data, billing and accounts receivable information with our bank, government tax auditors, and CPA auditors. We must meet many conditions in the law before we can share your service information for other purposes. For more information see: xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxxxxx/xxxxxxxxx/xxxxx.xxxx . Xxxx for your services We can use and share your health information to xxxx and get payment from health plans or other entities. Help with public health and safety issues We can share health information about you for certain situations such as: • Reporting suspected abuse, neglect, or domestic violence • Preventing or reducing a serious threat to anyone’s health or safety Comply with the law We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law. Address workers’ compensation, law enforcement, and other government requests We can use or share health information about you: • For workers’ compensation claims • For law enforcement purposes or with a law enforcement official • With oversight agencies for activities authorized by law Respond to covered County, State or Federal program requests We can share service information about you in response to a covered request by the county, state or federal program requests. Respond to lawsuits and legal actions We can share service information about you in response to a court or administrative order, or in response to a subpoena. Our Responsibilities • We are required by law to maintain the privacy and security of your protected health information. • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. • We must follow the duties and privacy practices described in this notice and give you a copy of it. • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. For more information see: xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxxxxx/xxxxxxxxx/xxxxxxxx.xxxx . Changes to the Terms of this Notice We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our website. Other Instructions for Notice • Effective Date of this Notice: 12/22/2020 • Privacy official: Xxxx Xxxxxxx, CEO 000 Xxxx Xx. Xxxxxxx Xxxxxx, Xx. Xxxxx, Xxxxxxxxx 00000 xxxx@xxxxxxx.xxx (320) 420-1017 • We never market or sell personal information • We will never share any service records without your written permission; excluding government entities entitled to the information File a complaint if you feel your rights are violated • You can complain if you feel we have violated your rights by contacting the privacy official listed above. • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 000 Xxxxxxxxxxxx Xxxxxx, X.X., Xxxxxxxxxx, X.X. 00000, calling 0-000-000-0000, or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. • We will not retaliate against you for filing a complaint. Initial Here Sign and Return to CDI Self-Directed Services Participant Agreement THIS AGREEMENT is made effective on , by and between CDI (Consumer Directions, Inc.) as the Financial Management Services (FMS) Entity and , Participant Employer or Managing Party. (Participant Employer or Managing Party Name)

Your Choices. For certain service health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to: • Share information with your family, close friends, or others involved in your care • Share information in a disaster relief situation If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety. In these cases, cases we never share your information unless you give us written permission: • Marketing purposes • Sale Most sharing of your information psychotherapy notes • In the case of fundraising, we may contact you for fundraising efforts, but you can tell us not to contact you again. Our Uses and Disclosures Serve We typically use or share your health information in the following ways. • Treat you We can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition. • Run our organization We can use and share your health information to run our practice, improve your care, and contact you when necessary. Example: We use health information about you to manage your treatment and services. • Bill for your services We can use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for your services. We are allowed or required to share your information in other ways – usually in ways that coordinate your services with contribute to the contracted or governing government agencies. Run our organization We are allowed or required to share some Participant Employer datapublic good, billing such as public health and accounts receivable information with our bank, government tax auditors, and CPA auditorsresearch. We must have to meet many conditions in the law before we can share your service information for other these purposes. For more information see: xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxxxxx/xxxxxxxxx/xxxxx.xxxx xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxxxxx/xxxxxxxxx/xxxxx.xxxx. Xxxx for your services We can use and share your health information to xxxx and get payment from health plans or other entities. • Help with public health and safety issues We can share health information about you for certain situations such as: • Reporting Preventing disease, reporting suspected abuse, neglect, or domestic violence • Preventing violence, and preventing or reducing a serious threat to anyone’s health or safety safety. • Do research We can use or share your information for health research. • Comply with the law We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law. • Work with a medical examiner or funeral director We can share health information with a coroner, medical examiner, or funeral director when an individual dies. • Address workers’ compensation, law enforcement, and other government requests We can use or share health information about you: • For you for workers’ compensation claims • For claims, for law enforcement purposes or with a law enforcement official • With official, with health oversight agencies for activities authorized by law Respond to covered Countylaw, State or Federal program requests We can share service information about you in response to a covered request by the countyand for special government functions such as military, state or federal program requests. national security, and presidential protective services • Respond to lawsuits and legal actions We can share service health information about you in response to a court or administrative order, or in response to a subpoena. Our Responsibilities • We are required by law to maintain the privacy and security of your protected health information. We retain records for 7 years past closure, or 7 years past a minor youth turning 18. • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. • We must follow the duties and privacy practices described in this notice and give you a copy of it. • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. For more information see: xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxxxxx/xxxxxxxxx/xxxxxxxx.xxxx . Changes to the Terms of this Notice This notice is effective 11/6/2019. We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our websiteweb site. Other Instructions for Notice 00000 Xxxxx Xxxx • Effective Date of this Notice: 12/22/2020 St. Louis, MO • Privacy official: Xxxx Xxxxxxx, CEO 000 Xxxx Xx. Xxxxxxx Xxxxxx, Xx. Xxxxx, Xxxxxxxxx 00000 xxxx@xxxxxxx.xxx (320) 42000000-1017 • We never market or sell personal information • We will never share any service records without your written permission; excluding government entities entitled to the information File a complaint if you feel your rights are violated • You can complain if you feel we have violated your rights by contacting the privacy official listed above. • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 000 Xxxxxxxxxxxx Xxxxxx, X.X., Xxxxxxxxxx, X.X. 00000, calling 0-0000 000-000-00000000 Phone • 000-000-0000 Fax xxxx@xxxxxxxxxxxxxxxxx.xxx • xxx.xxxxxxxxxxxxxxxxx.xxx This is to acknowledge that I have received Care and Counseling’s Privacy Notice Name Signature Date 00000 Xxxxx Xxxx • St. Louis, MO • 00000-0000 000-000-0000 Phone • 000-000-0000 Fax xxxx@xxxxxxxxxxxxxxxxx.xxx •xxx.xxxxxxxxxxxxxxxxx.xxx CLIENT GUIDE TO TELEHEALTH SERVICES “Telehealth Services” encompasses Video Therapy and Telephone Counseling. Telehealth involves the delivery of psychotherapy counseling services using electronic communications, information technology or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. • We other means between a mental health clinician employed by or otherwise contracted with Care and Counseling, Inc. (“Provider”) and a client who are not in the same physical location. Telehealth Services may be used for diagnosis, treatment, follow-up and/or education. Please note that prior to beginning Telehealth Services, new clients will be screened by phone by their Provider to ensure suitability for this treatment modality. Care and Counseling is dedicated to ensuring you receive the best possible care with minimal interruptions. Many clients and Providers are moving to Telehealth services during a national crisis and to ensure health, safety, and continuity of care. For most clients, services will return to meeting in the same physical location (Care and Counseling office) when possible and agreed upon between the client and Provider. Please discuss the duration of Telehealth Services with your Provider. This guide is intended to help you successfully participate in Telehealth Services. It is not retaliate against you for filing a complaint. Initial Here Sign exhaustive and Return to CDI Self-Directed Services Participant Agreement THIS AGREEMENT is made effective on , by and between CDI (Consumer Directions, Inc.) as the Financial Management Services (FMS) Entity and , Participant Employer or Managing Party. (Participant Employer or Managing Party Name)should not replace conversations with your Provider.

Your Choices. For certain service information, you can tell us your You have some choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, way that we use and we will follow your instructions. In these cases, you have both the right and choice to tell us toshare information as we: • Share information with Answer coverage questions from your family, close friends, or others involved in your care family and friends • Share information in a Provide disaster relief situation • Market our services and sell yourinformation. OUR USES AND DISCLOSURES We may also share your information when needed to lessen a serious and imminent threat to health or safety. In these cases, we never share your information unless you give us written permission: • Marketing purposes • Sale of your information Our Uses and Disclosures Serve you We are allowed or required to share your information in other ways – usually in ways that coordinate your services with the contracted or governing government agencies. Run our organization We are allowed or required to share some Participant Employer data, billing and accounts receivable information with our bank, government tax auditors, and CPA auditors. We must meet many conditions in the law before we can share your service information for other purposes. For more information see: xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxxxxx/xxxxxxxxx/xxxxx.xxxx . Xxxx for your services We can use and share your information as we: • Help manage the health information to xxxx and get payment from care treatment you receive • Run our organization • Pay for your health plans or other entities. services • Administer your health plan • Help with public health and safety issues We can share health information about you for certain situations such as: • Reporting suspected abuse, neglect, or domestic violence Do research • Preventing or reducing a serious threat to anyone’s health or safety Comply with the law We will share information about you if state • Respond to organ and tissue donation requests and work with a medical examiner or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law. funeral director • Address workers’ ' compensation, law enforcement, and other government requests We can use or share health information about you: • For workers’ compensation claims • For law enforcement purposes or with a law enforcement official • With oversight agencies for activities authorized by law Respond to covered County, State or Federal program requests We can share service information about you in response to a covered request by the county, state or federal program requests. Respond to lawsuits and legal actions • To assist in fundraising activities within our health care operations. YOUR RIGHTS When it comes to your health information, you have certain rights. This Section explains your rights and some of our responsibilities to help you. Get a copy of health and claims records • You can ask to see or get a copy of your health and claims records and other health information we have about you. Ask us how to do this. • We will provide a copy or a summary of your health and claims records, usually within 30 days of your request. We may charge a reasonable, cost-based fee. Ask us to correct health and claims records • You can share service information about ask us to correct your health and claims records if you think they are incorrect or incomplete. Ask us how to do this. • We may say "no" to your request, but we'll tell you why in writing within 60 days. Request confidential communications • You can ask us to contact you in response a specific way (for example, by home or office phone) or to send mail to a court different address. • We will consider all reasonable requests and must say "yes" if you tell us you would be in danger if we do not. Ask us to limit what we use or administrative ordershare • You can ask us not to use or share certain health information for treatment, payment, or in response to a subpoenaour operations. Our Responsibilities • We are not required by law to maintain agree to your request, and we may say "no" if it would affect your care. Get a list of those with whom we've shared information • You can ask for a list (accounting) of the times we've shared your health information for six years before the date you ask, whom we shared it with, and why. • We will include all the disclosures except treatment, payment, health care operations, and certain other disclosures (such as any you asked us to make). We'll provide one accounting a year for free but will charge a reasonable, cost-based fee if you request another within 12 months. Get a copy of this privacy notice • You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly. Choose someone to act for you • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and security of make choices about your protected health information. • We will let ensure the person has this authority and can act for you know promptly if a breach occurs that may have compromised the privacy or security of your informationbefore taking action. • We must follow the duties and privacy practices described in this notice and give you a copy of it. • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. For more information see: xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxxxxx/xxxxxxxxx/xxxxxxxx.xxxx . Changes to the Terms of this Notice We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our website. Other Instructions for Notice • Effective Date of this Notice: 12/22/2020 • Privacy official: Xxxx Xxxxxxx, CEO 000 Xxxx Xx. Xxxxxxx Xxxxxx, Xx. Xxxxx, Xxxxxxxxx 00000 xxxx@xxxxxxx.xxx (320) 420-1017 • We never market or sell personal information • We will never share any service records without your written permission; excluding government entities entitled to the information File a complaint if you feel your rights are violated • You can complain if you feel think we have violated your rights by contacting us using the privacy official listed aboveinformation on page 1. • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 000 Xxxxxxxxxxxx Xxxxxx, X.X., Xxxxxxxxxx, X.X. 00000, calling 0-000-000-0000, or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/ complaints/. • We will not retaliate against you for filing a complaint. Initial Here Sign and Return to CDI Self-Directed Services Participant Agreement THIS AGREEMENT is made effective on , by and between CDI (Consumer Directions, Inc.) as the Financial Management Services (FMS) Entity and , Participant Employer or Managing Party. (Participant Employer or Managing Party Name).

Your Choices. For certain service information, you can tell us your You have some choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, way that we use and we will follow your instructions. In these cases, you have both the right and choice to tell us toshare information as we: • Share information with Answer coverage questions from your family, close friends, or others involved in your care family and friends • Share information in a Provide disaster relief situation • Market our services and sell your information. OUR USES AND DISCLOSURES We may also share your information when needed to lessen a serious and imminent threat to health or safety. In these cases, we never share your information unless you give us written permission: • Marketing purposes • Sale of your information Our Uses and Disclosures Serve you We are allowed or required to share your information in other ways – usually in ways that coordinate your services with the contracted or governing government agencies. Run our organization We are allowed or required to share some Participant Employer data, billing and accounts receivable information with our bank, government tax auditors, and CPA auditors. We must meet many conditions in the law before we can share your service information for other purposes. For more information see: xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxxxxx/xxxxxxxxx/xxxxx.xxxx . Xxxx for your services We can use and share your information as we: • Help manage the health information to xxxx and get payment from care treatment you receive • Run our organization • Pay for your health plans or other entities. services • Administer your health plan • Help with public health and safety issues We can share health information about you for certain situations such as: • Reporting suspected abuse, neglect, or domestic violence Do research • Preventing or reducing a serious threat to anyone’s health or safety Comply with the law We will share information about you if state • Respond to organ and tissue donation requests and work with a medical examiner or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law. funeral director • Address workers’ compensation, law enforcement, and other government requests We can use or share health information about you: • For workers’ compensation claims • For law enforcement purposes or with a law enforcement official • With oversight agencies for activities authorized by law Respond to covered County, State or Federal program requests We can share service information about you in response to a covered request by the county, state or federal program requests. Respond to lawsuits and legal actions • To assist in fundraising activities within our health care operations. YOUR RIGHTS When it comes to your health information, you have certain rights. This Section explains your rights and some of our responsibilities to help you. Get a copy of health and claims records • You can ask to see or get a copy of your health and claims records and other health information we have about you. Ask us how to do this. • We will provide a copy or a summary of your health and claims records, usually within 30 days of your request. We may charge a reasonable, cost-based fee. Ask us to correct health and claims records • You can share service information about ask us to correct your health and claims records if you think they are incorrect or incomplete. Ask us how to do this. • We may say “no” to your request, but we’ll tell you why in writing within 60 days. Request confidential communications • You can ask us to contact you in response a specific way (for example, home or office phone) or to send mail to a court different address. • We will consider all reasonable requests and must say “yes” if you tell us you would be in danger if we do not. Ask us to limit what we use or administrative ordershare • You can ask us not to use or share certain health information for treatment, payment, or in response to a subpoenaour operations. Our Responsibilities • We are not required by law to maintain agree to your request, and we may say “no” if it would affect your care. Get a list of those with whom we’ve shared information • You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, whom we shared it with, and why. • We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost- based fee if you ask for another one within 12 months. Get a copy of this privacy notice • You can ask for a paper copy of this Notice at any time, even if you have agreed to receive the Notice electronically. We will provide you with a paper copy promptly. Choose someone to act for you • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and security of make choices about your protected health information. • We will let make sure the person has this authority and can act for you know promptly if a breach occurs that may have compromised the privacy or security of your informationbefore we take any action. • We must follow the duties and privacy practices described in this notice and give you a copy of it. • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. For more information see: xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxxxxx/xxxxxxxxx/xxxxxxxx.xxxx . Changes to the Terms of this Notice We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our website. Other Instructions for Notice • Effective Date of this Notice: 12/22/2020 • Privacy official: Xxxx Xxxxxxx, CEO 000 Xxxx Xx. Xxxxxxx Xxxxxx, Xx. Xxxxx, Xxxxxxxxx 00000 xxxx@xxxxxxx.xxx (320) 420-1017 • We never market or sell personal information • We will never share any service records without your written permission; excluding government entities entitled to the information File a complaint if you feel your rights are violated • You can complain if you feel we have violated your rights by contacting us using the privacy official listed aboveinformation on page 1. • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 000 Xxxxxxxxxxxx Xxxxxx, X.X., Xxxxxxxxxx, X.X. 00000, calling 0-000-000-0000, or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. • We will not retaliate against you for filing a complaint. Initial Here Sign and Return to CDI Self-Directed Services Participant Agreement THIS AGREEMENT is made effective on , by and between CDI (Consumer Directions, Inc.) as the Financial Management Services (FMS) Entity and , Participant Employer or Managing Party. (Participant Employer or Managing Party Name).

Your Choices. For certain service information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to: • Share information with your family, close friends, or others involved in your care • Share information in a disaster relief situation We may also share your information when needed to lessen a serious and imminent threat to health or safety. In these cases, we never share your information unless you give us written permission: • Marketing purposes • Sale of your information Our Uses and Disclosures Serve you We are allowed or required to share your information in other ways – usually in ways that coordinate your services with the contracted or governing government agencies. Run our organization We are allowed or required to share some Participant Employer data, billing and accounts receivable information with our bank, government tax auditors, and CPA auditors. We must meet many conditions in the law before we can share your service information for other purposes. For more information see: xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxxxxx/xxxxxxxxx/xxxxx.xxxx . Xxxx Bill for your services We can use and share your health information to xxxx bill and get payment from health plans or other entities. Help with public health and safety issues We can share health information about you for certain situations such as: • Reporting suspected abuse, neglect, or domestic violence • Preventing or reducing a serious threat to anyone’s health or safety Comply with the law We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law. Address workers’ compensation, law enforcement, and other government requests We can use or share health information about you: • For workers’ compensation claims • For law enforcement purposes or with a law enforcement official • With oversight agencies for activities authorized by law Respond to covered County, State or Federal program requests We can share service information about you in response to a covered request by the county, state or federal program requests. Respond to lawsuits and legal actions We can share service information about you in response to a court or administrative order, or in response to a subpoena. Our Responsibilities • We are required by law to maintain the privacy and security of your protected health information. • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. • We must follow the duties and privacy practices described in this notice and give you a copy of it. • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. For more information see: xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxxxxx/xxxxxxxxx/xxxxxxxx.xxxx . Changes to the Terms of this Notice We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our website. Other Instructions for Notice • Effective Date of this Notice: 12/22/2020 • Privacy official: Xxxx Xxxxxxx, CEO 000 Xxxx Xx. Xxxxxxx Xxxxxx, Xx. Xxxxx, Xxxxxxxxx 00000 xxxx@xxxxxxx.xxx (320000) 420000-1017 0000 • We never market or sell personal information • We will never share any service records without your written permission; excluding government entities entitled to the information File a complaint if you feel your rights are violated • You can complain if you feel we have violated your rights by contacting the privacy official listed above. • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 000 Xxxxxxxxxxxx Xxxxxx, X.X., Xxxxxxxxxx, X.X. 00000, calling 0-000-000-0000, or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. • We will not retaliate against you for filing a complaint. Initial Here Sign and Return to CDI Self-Directed Services Participant Agreement THIS AGREEMENT is made effective on , by and between CDI (Consumer Directions, Inc.) as the Financial Management Services (FMS) Entity and , Participant Employer or Managing Party. (Participant Employer or Managing Party Name)

Your Choices. For certain service health information, you can tell us me your choices about what we share. If you have a clear preference for how we I share your information in the situations described below, talk to usme. Tell us me what you want us to do, and we I will follow your instructions. In these cases, you have both the right and choice to tell us me to: • Share information with your family, close friends, or others involved in your care • Share information in a disaster relief situation We • Include your information in a hospital directory If you are not able to tell me your preference, for example if you are unconscious, I may go ahead and share your information if I believe it is in your best interest. I may also share your information when needed to lessen a serious and imminent threat to health or safety. In these cases, we cases I never share your information unless you give us me written permission: • Marketing purposes • Sale of your information Our • Most sharing of psychotherapy notes • In the case of fundraising: I may contact you for fundraising efforts, but you can tell me not to contact you again. My Uses and Disclosures Serve Disclosures: How do I typically use or share your health information? I typically use or share your health information in the following ways: • I can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition. • I can use and share your health information to run our practice, improve your care, and contact you when necessary. Example: We are use health information about you to manage your treatment and services. • I can use and share your health information to bill and get payment from health plans or other entities. Example: I give information about you to your health insurance plan so it will pay for your services. How else can I use or share your health information? I am allowed or required to share your information in other ways – usually in ways that coordinate your services with contribute to the contracted or governing government agenciespublic good, such as public health and research. Run our organization We are allowed or required I have to share some Participant Employer data, billing and accounts receivable information with our bank, government tax auditors, and CPA auditors. We must meet many conditions in the law before we I can share your service information for other these purposes. For more information see: xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxxxxx/xxxxxxxxx/xxxxx.xxxx xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxxxxx/xxxxxxxxx/xxxxx.xxxx. Xxxx for your services We can use and share your health information to xxxx and get payment from health plans or other entities. Help with public health and safety issues We I can share health information about you for certain situations such as: • Preventing disease • Helping with product recalls • Reporting adverse reactions to medications • Reporting suspected abuse, neglect, or domestic violence • Preventing or reducing a serious threat to anyone’s health or safety Comply • Do research. Compliance with the law We law: I will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re I’m complying with federal privacy law. • I can share health information about you with organ procurement organizations • I can work with a medical examiner or funeral director • I can share health information with a coroner, medical examiner, or funeral director when an individual dies • Address workers’ compensation, law enforcement, and other government requests We • I can use or share health information about you: • For you for workers’ compensation claims • For law enforcement purposes or with a law enforcement official • With health oversight agencies for activities authorized by law Respond to covered County• For special government functions such as military, State or Federal program requests We can share service information about you in response to a covered request by the countynational security, state or federal program requests. and presidential protective services • Respond to lawsuits and legal actions We • I can share service health information about you in response to a court or administrative order, or in response to a subpoena. Our Responsibilities • We are My Responsibilities: I am required by law to maintain the privacy and security of your protected health information. • We I will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. • We I must follow the duties and privacy practices described in this notice and give you a copy of it. • We I will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we me I can, you may change your mind at any time. Let us me know in writing if you change your mind. For more information see: xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxxxxx/xxxxxxxxx/xxxxxxxx.xxxx xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxxxxx/xxxxxxxxx/xxxxxxxx.xxxx. Changes to the Terms of this Notice We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our website. Other Instructions for Notice • Effective Date of this Notice: 12/22/2020 • Privacy official: Xxxx Xxxxxxx, CEO 000 Xxxx Xx. Xxxxxxx Xxxxxx, Xx. Xxxxx, Xxxxxxxxx 00000 xxxx@xxxxxxx.xxx (320) 420-1017 • We never not market or sell personal information • We will never share any service records without your written permission; excluding government entities entitled to the information File a complaint if you feel your rights are violated • You can complain if you feel we have violated your rights by contacting the privacy official listed above. • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 000 Xxxxxxxxxxxx Xxxxxx, X.X., Xxxxxxxxxx, X.X. 00000, calling 0-000-000-0000, or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. • We will not retaliate against you for filing a complaint. Initial Here Sign and Return to CDI Self-Directed Services Participant Agreement THIS AGREEMENT is made effective on , by and between CDI (Consumer Directions, Inc.) as the Financial Management Services (FMS) Entity and , Participant Employer or Managing Party. (Participant Employer or Managing Party Name)information.