Common use of Your Rights Clause in Contracts

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 an electronic or paper copy of your medical record U You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. U We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee. Ask us to correct your medical record U You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. U We may say “no” to your request, but we’ll tell you why in writing within 60 days. Request confidential communications U You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. U We will say “yes” to all reasonable requests. continued on next page œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i £ Your Rights continued Ask us to limit what we use or share U You can ask us not to use or share certain health information for treatment, payment, or our operations. U We are not required to agree to your request, and we may say “no” if it would affect your care. U If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. U We will say “yes” unless a law requires us to share that information. Get a list of those with whom we’ve shared information U 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, who we shared it with, and why. U 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 £Ó “œ˜Ì ð Get a copy of this privacy notice U 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 U If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. U We will make sure the person has this authority and can act for you before we take any action. File a complaint if you feel your rights are violated U You can complain if you feel we have violated your rights by contacting us ÕȘ} Ì i ˆ˜vœÀ“>̈œ˜ œ˜ «>}i £° U You can file a complaint with the U.S. Department of Health and Human -iÀۈVià "vwVi vœÀ CˆÛˆ ,ˆ} Ìà LÞ Ãi˜`ˆ˜} > iÌÌiÀ ̜ Óää I˜`i«i˜`i˜Vi AÛi˜Õi] -°7°] 7>à ˆ˜}̜˜] D°C° ÓäÓä£] V>ˆ˜} £‡nÇLJșȇÈÇÇx] œÀ visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. U We will not retaliate against you for filing a complaint. œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i Ó Your Choices For certain 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: U Share information with your family, close friends, or others involved in your care U Share information in a disaster relief situation U Include your information in a hospital directory U Contact you for fundraising efforts 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 we never share your information unless you give us written permission: U Marketing purposes U Sale of your information U Most sharing of psychotherapy notes In the case of fundraising: U We may contact you for fundraising efforts, but you can tell us not to contact you again. Our Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following ways. Treat you U We can use your health information and share it with other professionals who are treating you.

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 an electronic or paper copy of your medical record U You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. U We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-cost- based fee.  Ask us to correct your medical record U You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. U We may say “no” to your request, but we’ll tell you why in writing within 60 days.  Request confidential communications U You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. U We will say “yes” to all reasonable requests. continued on next page œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i £ Your Rights continued  Ask us to limit what we use or share U You can ask us not to use or share certain health information for treatment, payment, or our operations. U We are not required to agree to your request, and we may say “no” if it would affect your care. U If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. U We will say “yes” unless a law requires us to share that information.  Get a list of those with whom we’ve shared information U 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, who we shared it with, and why. U 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 £Ó “œ˜Ì ð 12 months.  Get a copy of this privacy notice U 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 U If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. U We will make sure the person has this authority and can act for you before we take any action.  File a complaint if you feel your rights are violated U You can complain if you feel we have violated your rights by contacting us ÕȘ} Ì i ˆ˜vœÀ“>̈œ˜ œ˜ «>}i £° U our Clinical Director and Privacy Officer, Xxxxx Xxxxxx, LCSW at 314.336.1041. You can also file a complaint with the U.S. Department of Health and Human -iÀۈVià "vwVi vœÀ CˆÛˆ ,ˆ} Ìà LÞ Ãi˜`ˆ˜} > iÌÌiÀ ̜ Óää I˜`i«i˜`i˜Vi AÛi˜Õi] Services Office for Civil Rights by sending a letter to 000 Xxxxxxxxxxxx Xxxxxx, X.X., Xxxxxxxxxx, X.X. 00000, calling 1-°7°] 7>à ˆ˜}̜˜] D°C° ÓäÓä£] V>ˆ˜} £‡nÇLJșȇÈÇÇx] œÀ 877- 000-0000, or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. U We will not retaliate against you for filing a complaint. œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i Ó Your Choices For certain 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: U  Share information with your family, close friends, or others involved in your care U  Share information in a disaster relief situation U Include your information in a hospital directory U Contact you for fundraising efforts 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 we never share your information unless you give us written permission: U  Marketing purposes U Sale of your information U  Most sharing of psychotherapy notes  In the case of fundraising: U We , we may contact you for fundraising efforts, but you can tell us not to contact you again. Our Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following ways. Treat you U We can use your health information and share it with other professionals who are treating you.

Your Rights. When it comes You have the right to: - Obtain a copy of your paper or electronic medical record o You can ask to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you. Get view or receive an electronic or paper copy of your medical record U You can record. Please ask to see or get an electronic or paper copy of your medical record and other health information we have about youthe office manager for more information. Ask us how to do this. U o We will provide a copy or a summary of your health information, usually information within 30 days of your request. We may charge a reasonable, cost-based fee, depending on the size and nature of the request. Ask us to - Update and/or correct your paper or electronic medical record U (this does not pertain to clinical impressions) o You can ask us to update and/or correct health information about you that you think believe is incorrect or incompleteincomplete (this does not pertain to clinical impressions). Ask us how Please discuss this with your provider. o We reserve the right to do thisdeny these changes, in which case you may ask for a written explanation of the reason your request was denied. U We may say “no” have 60 days to your request, but we’ll tell you why in writing within 60 dayscomply. - Request confidential communications U communication o You can ask us to contact you in you, or not contact you, using a specific way form of communication (for example, home telephone or office phoneemail) or to send mail to a different address. U o We will say “yes” do our best to meet all reasonable requests. continued on next page œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i £ Your Rights continued - Ask us to limit what the information we share or use or share U o You can ask us not to use or share certain health information for treatment, payment, or our operations. U We are not required to agree to meet your request, and we may say “no” deny your request if it would affect your care. U o If you pay for a service or health care item out-of-pocket in full, without assistance from your insurance provider, you can may ask us not to share that information for the purpose of payment or our operations with your health insurer. U We will say “yes” comply with all reasonable requests unless a law requires us to share that information. Get - Obtain a list of those with whom we’ve shared information U You can ask for a list (accounting) of the times we’ve we have shared your health information for six years prior to the date you ask, who we shared it with, and why. U 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 £Ó “œ˜Ì ð Get - Obtain a copy of this privacy notice U o 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 U on your behalf o If you have given someone medical power of attorney or if someone is your has legal guardianguardianship over you, that person can may exercise your rights and make choices about your health information. U o We will make sure verify this person’s authority to the person has this authority and can act for you best of our ability before we take any action. - File a complaint if you feel believe your privacy rights are have been violated U o You can complain issue a complaint if you feel we have Gladstone Psychiatry & Wellness has violated your rights rights. To do so, please speak with the officer manager and/or ask to be contacted by contacting us ÕȘ} Ì i ˆ˜vœÀ“>̈œ˜ œ˜ «>}i £° U the Chief Clinical Officer. You can call 000-000-0000 to reach our phone directory. o You can file a complaint with the U.S. Department of Health and Human -iÀۈVià "vwVi vœÀ CˆÛˆ ,ˆ} Ìà LÞ Ãi˜`ˆ˜} > iÌÌiÀ ̜ Óää I˜`i«i˜`i˜Vi AÛi˜Õi] Services Office for Civil Rights via letter, telephone or online. § Address: 000 Xxxxxxxxxxxx Xxxxxx, X.X., Xxxxxxxxxx, XX, 00000 § Phone Number: 0-°7°] 7>à ˆ˜}̜˜] D°C° ÓäÓä£] V>ˆ˜} £‡nÇLJșȇÈÇÇx] œÀ visiting 000-000-0000 § Website: xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. U o We will not retaliate against you for exercising your rights and filing a complaint. œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i Ó Your Choices For certain 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: U Share information with your family, close friends, or others involved in your care U Share information in a disaster relief situation U Include your information in a hospital directory U Contact you for fundraising efforts 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 we never share your information unless you give us written permission: U Marketing purposes U Sale of your information U Most sharing of psychotherapy notes In the case of fundraising: U We may contact you for fundraising efforts, but you can tell us not to contact you again. Our Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following ways. Treat you U We can use your health information and share it with other professionals who are treating you.

Your Rights. You have the right to: • Get a copy of your paper or electronic service record • Correct your paper or electronic service record • Request confidential communication • Ask us to limit the information we share • Get a list of those with whom we’ve shared your information • Get a copy of this privacy notice • Choose someone to act for you • File a complaint if you believe your privacy rights have been violated Your Choices You have some choices in the way that we use and share information as we: • Discuss your services with family, friends and caregivers • Provide disaster relief • Provide services • Market our services Our Uses and Disclosures We may use and share your information as we: • Serve you • Run our organization • Xxxx for your services • Help with public health and safety issues • Comply with the law • Respond to required county, state and federal program requests • Address workers’ compensation, law enforcement, and other government requests • Respond to lawsuits and legal actions 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 an electronic or paper copy of your medical service record U • You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. U • We will provide a copy or a summary of your health service information, usually within 30 days of your request. We may charge a reasonable, cost-based fee. Ask us to correct your medical service record U • You can ask us to correct health any information about you that you think is incorrect or incomplete. Ask us how to do this. U • We may say “no” to your request, but we’ll tell you why in writing within 60 days. Request confidential communications U • You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. U • We will say “yes” to all reasonable requests. continued on next page œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i £ Your Rights continued Ask us to limit what we use or share U • You can ask us not to use or share certain health information for treatmentservices, payment, or our operations. U We are not required to agree to your request, and we may say “no” if it would affect your careservices or our legal obligation. U • If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. U We will say “yes” unless a law requires us to share that information. Get a list of those with whom we’ve shared information U • You can ask for a list (accounting) of the times we’ve shared your health service information for six years prior to the date you ask, who we shared it with, and why. U • We will include all the disclosures except for those about treatmentservices, 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 £Ó “œ˜Ì ð 12 months. Get a copy of this privacy notice U 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 U • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health service information. U • We will make sure the person has this authority and can act for you before we take any action. File a complaint if you feel your rights are violated U You can complain if you feel we have violated your rights by contacting us ÕȘ} Ì i ˆ˜vœÀ“>̈œ˜ œ˜ «>}i £° U You can file a complaint with the U.S. Department of Health and Human -iÀۈVià "vwVi vœÀ CˆÛˆ ,ˆ} Ìà LÞ Ãi˜`ˆ˜} > iÌÌiÀ ̜ Óää I˜`i«i˜`i˜Vi AÛi˜Õi] -°7°] 7>à ˆ˜}̜˜] D°C° ÓäÓä£] V>ˆ˜} £‡nÇLJșȇÈÇÇx] œÀ visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. U We will not retaliate against you for filing a complaint. œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i Ó Your Choices For certain 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: U Share information with your family, close friends, or others involved in your care U Share information in a disaster relief situation U Include your information in a hospital directory U Contact you for fundraising efforts 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 we never share your information unless you give us written permission: U Marketing purposes U Sale of your information U Most sharing of psychotherapy notes In the case of fundraising: U We may contact you for fundraising efforts, but you can tell us not to contact you again. Our Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following ways. Treat you U We can use your health information and share it with other professionals who are treating you.

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 an electronic or paper copy of your medical record U You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. U We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-cost- based fee. • Ask us to correct your medical record U You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. U We may say “no” to your request, but we’ll tell you why in writing within 60 days. • Request confidential communications U You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. U We will say “yes” to all reasonable requests. continued on next page œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i £ Your Rights continued • Ask us to limit what we use or share U You can ask us not to use or share certain health information for treatment, payment, or our operations. U We are not required to agree to your request, and we may say “no” if it would affect your care. U If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. U We will say “yes” unless a law requires us to share that information. • Get a list of those with whom we’ve shared information U 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, who we shared it with, and why. U 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 £Ó “œ˜Ì ð 12 months. • Get a copy of this privacy notice U 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 U If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. U We will make sure the person has this authority and can act for you before we take any action. • File a complaint if you feel your rights are violated U You can complain if you feel we have violated your rights by contacting us ÕȘ} Ì i ˆ˜vœÀ“>̈œ˜ œ˜ «>}i £° U our Clinical Director and Privacy Officer, Xxxxx Xxxxxx, LCSW at 314.336.1041. You can also file a complaint with the U.S. Department of Health and Human -iÀۈVià "vwVi vœÀ CˆÛˆ ,ˆ} Ìà LÞ Ãi˜`ˆ˜} > iÌÌiÀ ̜ Óää I˜`i«i˜`i˜Vi AÛi˜Õi] Services Office for Civil Rights by sending a letter to 000 Xxxxxxxxxxxx Xxxxxx, X.X., Xxxxxxxxxx, X.X. 00000, calling 1-°7°] 7>à ˆ˜}̜˜] D°C° ÓäÓä£] V>ˆ˜} £‡nÇLJșȇÈÇÇx] œÀ 877- 000-0000, or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. U We will not retaliate against you for filing a complaint. œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i Ó Your Choices For certain 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: U • Share information with your family, close friends, or others involved in your care U • Share information in a disaster relief situation U Include your information in a hospital directory U Contact you for fundraising efforts Notice of Privacy Practices (Rev. 11/6/2019) 1 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 we never share your information unless you give us written permission: U • Marketing purposes U Sale of your information U • Most sharing of psychotherapy notes • In the case of fundraising: U We , we may contact you for fundraising efforts, but you can tell us not to contact you again. Our Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following ways. Treat you U We can use your health information and share it with other professionals who are treating you.

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 an electronic or paper copy of your medical record U You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. We retain records for 7 years after termination, or 7 years after a minor youth turns 18. Ask us how to do this. U We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee. • Ask us to correct your medical record U You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. U We may say “no” to your request, but we’ll tell you why in writing within 60 days. • Request confidential communications U You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. U We will say “yes” to all reasonable requests. continued on next page œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i £ Your Rights continued • Ask us to limit what we use or share U You can ask us not to use or share certain health information for treatment, payment, or our operations. U We are not required to agree to your request, and we may say “no” if it would affect your care. U If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. U We will say “yes” unless a law requires us to share that information. • Get a list of those with whom we’ve shared information U 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, who we shared it with, and why. U 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 £Ó “œ˜Ì ð 12 months. • Get a copy of this privacy notice U 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 U If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. U We will make sure the person has this authority and can act for you before we take any action. • File a complaint if you feel your rights are violated U You can complain if you feel we have violated your rights by contacting us ÕȘ} Ì i ˆ˜vœÀ“>̈œ˜ œ˜ «>}i £° U our Clinical Director and Privacy Officer, Xxxxx Xxxxxx, LCSW at 314.336.1041. You can also file a complaint with the U.S. Department of Health and Human -iÀۈVià "vwVi vœÀ CˆÛˆ ,ˆ} Ìà LÞ Ãi˜`ˆ˜} > iÌÌiÀ ̜ Óää I˜`i«i˜`i˜Vi AÛi˜Õi] Services Office for Civil Rights by sending a letter to 000 Xxxxxxxxxxxx Xxxxxx, X.X., Xxxxxxxxxx, X.X. 00000, calling 0-°7°] 7>à ˆ˜}̜˜] D°C° ÓäÓä£] V>ˆ˜} £‡nÇLJșȇÈÇÇx] œÀ 000-000-0000, or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. U Notice of Privacy Practices (Rev. 11/6/2019) 1 We will not retaliate against you for filing a complaint. œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i Ó Your Choices For certain 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: U Share information with your family, close friends, or others involved in your care U Share information in a disaster relief situation U Include your information in a hospital directory U Contact you for fundraising efforts 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 we never share your information unless you give us written permission: U Marketing purposes U Sale of your information U Most sharing of psychotherapy notes In the case of fundraising: U We may contact you for fundraising efforts, but you can tell us not to contact you again. Our Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following ways. Treat you U We can use your health information and share it with other professionals who are treating you.

Your Rights. You have the right to: • Get a copy of your paper or electronic medical record • Correct your paper or electronic medical record • Request confidential communication • Ask us to limit the information we share • Get a list of those with whom we’ve shared your information • Get a copy of this privacy notice • Choose someone to act for you • File a complaint if you believe your privacy rights have been violated Your Choices You have some choices in the way that we use and share information as we: • Tell family and friends about your condition • Provide disaster relief • Include you in a hospital directory • Provide mental healthcare • Market our services and sell your information • Raise funds Our Uses and Disclosures We may use and share your information as we: • Treat you • Run our organization • Bill for your services • Improve care for all our patients, for example by teaching • Help with public health and safety issues • Do research • Comply with the law • Respond to organ and tissue donation requests • Work with a medical examiner or funeral director • Address workers’ compensation, law enforcement, and other government requests • Respond to lawsuits and legal actions 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 an electronic or paper copy of your medical record U • You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. U • We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee. • Ask us to correct your medical record U • You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. U • We may say “no” to your request, but we’ll tell you why in writing within 60 days. • Request confidential communications U communications. • You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. U • We will say “yes” to all reasonable requests. continued on next page œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i £ Your Rights continued Ask us to limit what we use or share U • You can ask us not to use or share certain health information for treatment, payment, or our operations. U We are not required to agree to your request, and we may say “no” if it would affect your care. U • If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. U We will say “yes” unless a law requires us to share that information. • Get a list of those with whom we’ve shared information U 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, who we shared it with, and why. U • We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such disclosures(such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-cost- based fee if you ask for another one within £Ó “œ˜Ì ð 12 months. Get a copy of this privacy notice U 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 U • If you have given someone a health care proxy, medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. U • We will make sure the person has this authority and can act for you before we take any action. File a complaint if you feel your rights are violated U • You can complain if you feel we have violated your rights by contacting us ÕȘ} Ì i ˆ˜vœÀ“>̈œ˜ œ˜ «>}i £° U our Patient Relations Office at (000) 000-0000. • You can file a complaint with the U.S. Department of Health and Human -iÀۈVià "vwVi vœÀ CˆÛˆ ,ˆ} Ìà LÞ Ãi˜`ˆ˜} > iÌÌiÀ ̜ Óää I˜`i«i˜`i˜Vi AÛi˜Õi] Services Office for Civil Rights by sending a letter to 000 Xxxxxxxxxxxx Xxxxxx, X.X., Xxxxxxxxxx, X.X. 00000, calling 0-°7°] 7>à ˆ˜}̜˜] D°C° ÓäÓä£] V>ˆ˜} £‡nÇLJșȇÈÇÇx] œÀ visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. U 000-000-0000, or visiting: xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx. • We will not retaliate against you for filing a complaint. œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i Ó Your Choices For certain 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: U Share information with your family, close friends, or others involved in your care U Share information in a disaster relief situation U Include your information in a hospital directory U Contact you for fundraising efforts 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 we never share your information unless you give us written permission: U Marketing purposes U Sale of your information U Most sharing of psychotherapy notes In the case of fundraising: U We may contact you for fundraising efforts, but you can tell us not to contact you again. Our Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following ways. Treat you U We can use your health information and share it with other professionals who are treating you.

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 an electronic or paper copy of your medical record U You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. U We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee. Ask us to correct your medical record U You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. U We may say “no” to your request, but we’ll tell you why in writing within 60 days. Request confidential confidential communications U You can ask us to contact you in a specific specific way (for example, home or office office phone) or to send mail to a different address. U We will say “yes” to all reasonable requests. continued on next page œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i £ Your Rights continued Ask us to limit what we use or share U You can ask us not to use or share certain health information for treatment, payment, or our operations. U We are not required to agree to your request, and we may say “no” if it would affect your care. U If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. U We will say “yes” unless a law requires us to share that information. Get a list of those with whom we’ve shared information U 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, who we shared it with, and why. U 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 £Ó “œ˜Ì ð Get a copy of this privacy notice U 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 U If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. U We will make sure the person has this authority and can act for you before we take any action. File a complaint if you feel your rights are violated U You can complain if you feel we have violated your rights by contacting us ÕȘ} Ì i ˆ˜vœÀ“>̈œ˜ œ˜ «>}i £° U You can file file a complaint with the U.S. Department of Health and Human -iÀۈVià "vwVi vœÀ CˆÛˆ ,ˆ} Ìà LÞ Ãi˜`ˆ˜} > iÌÌiÀ ̜ Óää I˜`i«i˜`i˜Vi AÛi˜Õi] -°7°] 7>à ˆ˜}̜˜] D°C° ÓäÓä£] V>ˆ˜} £‡nÇLJșȇÈÇÇx] œÀ visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. U We will not retaliate against you for filing filing a complaint. œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i Ó Your Choices For certain 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: U Share information with your family, close friends, or others involved in your care U Share information in a disaster relief situation U Include your information in a hospital directory U Contact you for fundraising efforts 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 we never share your information unless you give us written permission: U Marketing purposes U Sale of your information U Most sharing of psychotherapy notes In the case of fundraising: U We may contact you for fundraising efforts, but you can tell us not to contact you again. Our Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following ways. Treat you U We can use your health information and share it with other professionals who are treating you.

Your Rights. You have the right to: • Get a copy of your paper or electronic records maintained by us • Request confidential communication • Ask us to limit the information we share • Get a list of those with whom we’ve shared your information • Get a copy of this privacy notice Your Choices You have some choices in the way that we use and share information as we: • Communicate with others about the work we do for you • Market our services Our Uses and Disclosures We may use and share your information as we: • Coach you • Run our organization • Bill for your services • Help with public health and safety issues • Do research • Comply with the law • Address workers’ compensation, law enforcement, and other government requests • Respond to lawsuits and legal actions 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 an electronic or paper a copy of your medical record U coaching records • You can ask to see or get an electronic or paper copy of your medical record coaching records and other health information we have about you. Ask us how to do this. U • We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee. Ask us to correct your medical record U You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. U We may say “no” to your request, but we’ll tell you why in writing within 60 days. Request confidential communications U • You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. U We will say “yes” to all reasonable requests. continued on next page œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i £ Your Rights continued Ask us to limit what we use or share U • You can ask us not to use or share certain health information for treatmentcoaching, payment, or our operations. U We are In certain limited circumstances, we may not required to agree to your request, and but we may say “no” if it would affect your care. U If will tell you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. U We will say “yes” unless a law requires us to share that informationwhy. Get a list of those with whom we’ve shared information U • You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you askinformation, who we shared it with, and why. U 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 £Ó “œ˜Ì ð Get a copy of this privacy notice U • You can ask for a paper copy of this notice at any time, even if you have agreed to receive already received the notice electronically. We will provide you with a paper copy promptly. Choose someone to act for you U • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. U • We will make sure the person has this authority and can act for you before we take any action. File a complaint if you feel your rights are violated U • You can complain if you feel we have violated your rights by contacting us ÕȘ} Ì i ˆ˜vœÀ“>̈œ˜ œ˜ «>}i £° U You can file a complaint with using the U.S. Department of Health and Human -iÀۈVià "vwVi vœÀ CˆÛˆ ,ˆ} Ìà LÞ Ãi˜`ˆ˜} > iÌÌiÀ ̜ Óää I˜`i«i˜`i˜Vi AÛi˜Õi] -°7°] 7>à ˆ˜}̜˜] D°C° ÓäÓä£] V>ˆ˜} £‡nÇLJșȇÈÇÇx] œÀ visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. U We will not retaliate against you for filing a complaint. œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i Ó Your Choices For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information listed 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: U Share information with your family, close friends, or others involved in your care U Share information in a disaster relief situation U Include your information in a hospital directory U Contact you for fundraising efforts 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 we never share your information unless you give us written permission: U Marketing purposes U Sale of your information U Most sharing of psychotherapy notes In the case of fundraising: U We may contact you for fundraising efforts, but you can tell us not to contact you again. Our Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following ways. Treat you U We can use your health information and share it with other professionals who are treating youthis notice.

Your Rights. When it comes to your health information, you have certain rights. This section explains those rights. Ask to see a copy of your rights medical record. If you would like to see a copy of your medical records, just let us know. We will grant your written request during business hours within 5 working days of the request. The records can be viewed by you or your personal representative, and some either you or the representative may bring one person of our responsibilities to help youyour choosing. Get an electronic or paper copy of your medical record U record. • You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. U • We will provide a copy or a summary of your health information, usually within 30 15 days of your request. We may charge a reasonable, cost-based feefee of $0.25 per page. • If your request for a copy is for the purpose of supporting a claim or appeal for public benefits, then the fee will be waived and one free copy will be provided within 30 days. • In lieu of access to the entire record, we may instead provide a summary including your medication list, within 10 working days of your request, unless your record is lengthy, then we may need additional time, not to exceed 30 days. We may charge a reasonable fee for the time it takes to prepare the summary. • If your medical records include mental health records, we may decline to provide access to these records if we feel there is a substantial risk of significant adverse or detrimental consequences of such access. However, we will release those records to a qualified professional. Ask us to correct your medical record U record. • You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how If you wish, you can write an addendum of up to do this. U We may say “no” 250 words per incorrect or incomplete item; this addendum will be added to your request, but we’ll tell you why medical records and will clearly indicate in writing within 60 daysthat you request the addendum to be made a part of your records. Request confidential communications U communications. • You can ask us to contact you in a specific way (for example, home or office phone) ), or to send mail to a different address. U • We will say “yes” agree to all reasonable requests. continued on next page œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i £ Your Rights continued Ask us to limit what we use or share U share. • You can ask us not to use or share certain health information for treatment, payment, or our operations. U We are not required to agree to your request, and we may say “no” if it would could affect your care. U • If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. U We will say “yes” unless a law requires us to share that information. Get a list of those with whom we’ve shared information U information. • You can ask for a list (an accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. U • 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 We will provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within £Ó “œ˜Ì ð 12 months. Get a copy of this privacy notice U 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 U you. • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. U • We will make sure the person has this authority and can act for you before we take any action. File a complaint if you feel your rights are violated U You can complain violated. • Please let us know if you feel we have violated your rights by contacting not upheld our obligations. Contact us ÕȘ} Ì i ˆ˜vœÀ“>̈œ˜ œ˜ «>}i £° U using the information on page 1 of this Notice. • You can file a complaint with the U.S. Department of Health and Human -iÀۈVià "vwVi vœÀ CˆÛˆ ,ˆ} Ìà LÞ Ãi˜`ˆ˜} > iÌÌiÀ ̜ Óää I˜`i«i˜`i˜Vi AÛi˜Õi] Services Office for Civil Rights by sending a letter to 000 Xxxxxxxxxxxx Xxxxxx, X.X., Xxxxxxxxxx, X.X. 00000, calling 0-°7°] 7>à ˆ˜}̜˜] D°C° ÓäÓä£] V>ˆ˜} £‡nÇLJșȇÈÇÇx] œÀ 000-000-0000, or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. U • We will not retaliate against you for filing a complaint. œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i Ó Your Choices For certain 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: U Share information with your family, close friends, or others involved in your care U Share information in a disaster relief situation U Include your information in a hospital directory U Contact you for fundraising efforts 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 we never share your information unless you give us written permission: U Marketing purposes U Sale of your information U Most sharing of psychotherapy notes In the case of fundraising: U We may contact you for fundraising efforts, but you can tell us not to contact you again. Our Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following ways. Treat you U We can use your health information and share it with other professionals who are treating you.

Your Rights. When it comes You have the right to: - Obtain a copy of your paper or electronic medical record o You can ask to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you. Get view or receive an electronic or paper copy of your medical record U You can record. Please ask to see or get an electronic or paper copy of your medical record and other health information we have about youthe office manager for more information. Ask us how to do this. U o We will provide a copy or a summary of your health information, usually information within 30 days of your request. We may charge a reasonable, cost-based fee, depending on the size and nature of the request. Ask us to - Update and/or correct your paper or electronic medical record U (this does not pertain to clinical impressions) o You can ask us to update and/or correct health information about you that you think believe is incorrect or incompleteincomplete (this does not pertain to clinical impressions). Ask us how Please discuss this with your provider. o We reserve the right to do thisdeny these changes, in which case you may ask for a written explanation of the reason your request was denied. U We may say “no” have 60 days to your request, but we’ll tell you why in writing within 60 dayscomply. - Request confidential communications U communication o You can ask us to contact you in you, or not contact you, using a specific way form of communication (for example, home telephone or office phoneemail) or to send mail to a different address. U o We will say “yes” do our best to meet all reasonable requests. continued on next page œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i £ Your Rights continued - Ask us to limit what the information we share or use or share U o You can ask us not to use or share certain health information for treatment, payment, or our operations. U We are not required to agree to meet your request, and we may say “no” deny your request if it would affect your care. U o If you pay for a service or health care item out-of-pocket in full, without assistance from your insurance provider, you can may ask us not to share that information for the purpose of payment or our operations with your health insurer. U We will say “yes” comply with all reasonable requests unless a law requires us to share that information. Get - Obtain a list of those with whom we’ve shared information U You can ask for a list (accounting) of the times we’ve we have shared your health information for six years prior to the date you ask, who we shared it with, and why. U 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 £Ó “œ˜Ì ð Get - Obtain a copy of this privacy notice U o 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 U on your behalf o If you have given someone medical power of attorney or if someone is your has legal guardianguardianship over you, that person can may exercise your rights and make choices about your health information. U o We will make sure verify this person’s authority to the person has this authority and can act for you best of our ability before we take any action. - File a complaint if you feel believe your privacy rights are have been violated U o You can complain issue a complaint if you feel we have Gladstone Psychiatry & Wellness has violated your rights rights. To do so, please speak with the officer manager and/or ask to be contacted by contacting us ÕȘ} Ì i ˆ˜vœÀ“>̈œ˜ œ˜ «>}i £° U the Chief Clinical Officer. You can call 000-000-0000 to reach our phone directory. o You can file a complaint with the U.S. Department of Health and Human -iÀۈVià "vwVi vœÀ CˆÛˆ ,ˆ} Ìà LÞ Ãi˜`ˆ˜} > iÌÌiÀ ̜ Óää I˜`i«i˜`i˜Vi AÛi˜Õi] Services Office for Civil Rights via letter, telephone or online. ▪ Address: 000 Xxxxxxxxxxxx Xxxxxx, X.X., Xxxxxxxxxx, XX, 00000 ▪ Phone Number: 0-°7°] 7>à ˆ˜}̜˜] D°C° ÓäÓä£] V>ˆ˜} £‡nÇLJșȇÈÇÇx] œÀ visiting 000-000-0000 ▪ Website: xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. U o We will not retaliate against you for exercising your rights and filing a complaint. œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i Ó Your Choices For certain 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: U Share information with your family, close friends, or others involved in your care U Share information in a disaster relief situation U Include your information in a hospital directory U Contact you for fundraising efforts 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 we never share your information unless you give us written permission: U Marketing purposes U Sale of your information U Most sharing of psychotherapy notes In the case of fundraising: U We may contact you for fundraising efforts, but you can tell us not to contact you again. Our Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following ways. Treat you U We can use your health information and share it with other professionals who are treating you.

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 an electronic or paper a copy of your medical record U * You can ask to see or get an electronic or paper a copy of your medical record health and claims records and other health and claims records health information we have about you. Ask us how to do thisthis by using the contact information at the end of this notice. U * We will provide a copy or a summary of your health information, and claims records usually within 30 days of your the request. We may charge a reasonable, cost-based fee. Ask us to correct your medical record U health * You can ask us to correct your health information about you that and claims records if you think is and claims records they are incorrect or incomplete. Ask us how to do thisthis by using the contact information at the end of this notice. U * We may say “no” to your request, but we. We’ll tell you why in writing within 60 days. Request confidential communications U * You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different addresscommunications address Ask us how to do this by using the contact information at the end of this notice. U * We will consider all reasonable requests, and must say “yes” to all reasonable requestsif you tell us you would be in danger if we do not. continued on next page œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i £ Your Rights continued Ask us to limit what we use or share U * You can ask us not to share or use or share certain health information for we use or share treatment, payment, payment or our operations. U Ask how to do this by using the contact information at the end of this notice. * We are not required to agree to your request, and we may say “no” if it would affect your care. U If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. U We will say “yes” unless a law requires us to share that information. Get a list of those with whom we’ve shared information U * You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the your request date you askof whom we’ve shared when we shared your information, who we shared it with, with and why. U Ask us how information to do this by using the contact information at the end of this notice. * We will include all the disclosures except for those about treatment, payment, and health care our operations, and certain other disclosures (such as any you asked us to make). We’ll We will provide one accounting a year for free but will we may charge a reasonable, cost-based fee if you ask for another one within £Ó “œ˜Ì ð 12 months. Get a copy of this privacy notice U * You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We To request a copy of this notice, use the contact information at the end of this notice and we will provide send you with a paper copy one promptly. Choose someone to act for you U * If you have given someone medical power of attorney or if someone is your legal for you guardian, that person can exercise your rights and make choices about your health information. U Ask us how to do this by using the contact information at the end of this notice. * We will make sure confirm the person has this the authority and can act for you before we take any actionshare your information. YOUR RIGHTS (continued) File a complaint if you feel your rights are violated U * You can complain if you feel we have violated your privacy rights by contacting us ÕȘ} Ì i ˆ˜vœÀ“>̈œ˜ œ˜ «>}i £° U using the you feel your rights contact information at the end of this notice. are violated * You can also file a complaint with the U.S. Department of Health and Human -iÀۈVià "vwVi vœÀ CˆÛˆ ,ˆ} Ìà LÞ Ãi˜`ˆ˜} > iÌÌiÀ ̜ Óää I˜`i«i˜`i˜Vi AÛi˜Õi] Services Office for Civil Rights by calling 0-°7°] 7>à ˆ˜}̜˜] D°C° ÓäÓä£] V>ˆ˜} £‡nÇLJșȇÈÇÇx] œÀ 000-000-0000; or by visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. U xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/ or by sending a letter to them at: 000 Xxxxxxxxxxxx Xxx., XX, Xxxxxxxxxx, X.X. 00000. * We will not retaliate against you for filing a complaint. œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i Ó Your Choices For certain 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: U Share information with your family, close friends, or others involved in your care U Share information in a disaster relief situation U Include your information in a hospital directory U Contact you for fundraising efforts 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 we never share your information unless you give us written permission: U Marketing purposes U Sale of your information U Most sharing of psychotherapy notes In the case of fundraising: U We may contact you for fundraising efforts, but you can tell us not to contact you again. Our Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following ways. Treat you U We can use your health information and share it with other professionals who are treating you.

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 an electronic or paper copy of your medical record U You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. U We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-cost- based fee. • Ask us to correct your medical record U You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. U We may say “no” to your request, but we’ll tell you why in writing within 60 days. • Request confidential communications U You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. U We will say “yes” to all reasonable requests. continued on next page œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i £ Your Rights continued • Ask us to limit what we use or share U You can ask us not to use or share certain health information for treatment, payment, or our operations. U We are not required to agree to your request, and we may say “no” if it would affect your care. U If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. U We will say “yes” unless a law requires us to share that information. • Get a list of those with whom we’ve shared information U 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, who we shared it with, and why. U 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 £Ó “œ˜Ì ð 12 months. • Get a copy of this privacy notice U 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 U If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. U We will make sure the person has this authority and can act for you before we take any action. • File a complaint if you feel your rights are violated U You can complain if you feel we have violated your rights by contacting us ÕȘ} Ì i ˆ˜vœÀ“>̈œ˜ œ˜ «>}i £° U You can file a complaint with the U.S. Department of Health and Human -iÀۈVià "vwVi vœÀ CˆÛˆ ,ˆ} Ìà LÞ Ãi˜`ˆ˜} > iÌÌiÀ ̜ Óää I˜`i«i˜`i˜Vi AÛi˜Õi] -°7°] 7>à ˆ˜}̜˜] D°C° ÓäÓä£] V>ˆ˜} £‡nÇLJșȇÈÇÇx] œÀ visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. U We will not retaliate against you Services Office for filing a complaint. œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i Ó Your Choices For certain 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: U Share information with your family, close friends, or others involved in your care U Share information in a disaster relief situation U Include your information in a hospital directory U Contact you for fundraising efforts 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 we never share your information unless you give us written permission: U Marketing purposes U Sale of your information U Most sharing of psychotherapy notes In the case of fundraising: U We may contact you for fundraising efforts, but you can tell us not to contact you again. Our Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following ways. Treat you U We can use your health information and share it with other professionals who are treating you.Civil Rights by:

Your Rights. You have the right to: Get a copy of your paper or electronic service record Correct your paper or electronic service record Request confidential communication Ask us to limit the information we share Get a list of those with whom we’ve shared your information Get a copy of this privacy notice Choose someone to act for you File a complaint if you believe your privacy rights have been violated Your Choices You have some choices in the way that we use and share information as we: Discuss your services with family, friends and caregivers Provide disaster relief Provide services Market our services Our Uses and Disclosures We may use and share your information as we: Serve you Run our organization Xxxx for your services Help with public health and safety issues Comply with the law Respond to required county, state and federal program requests Address workers’ compensation, law enforcement, and other government requests Respond to lawsuits and legal actions 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 an electronic or paper copy of your medical service record U You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. U We will provide a copy or a summary of your health service information, usually within 30 days of your request. We may charge a reasonable, cost-based fee. Ask us to correct your medical service record U You can ask us to correct health any information about you that you think is incorrect or incomplete. Ask us how to do this. U We may say “no” to your request, but we’ll tell you why in writing within 60 days. Request confidential communications U You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. U We will say “yes” to all reasonable requests. continued on next page œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i £ Your Rights continued Ask us to limit what we use or share U You can ask us not to use or share certain health information for treatmentservices, payment, or our operations. U We are not required to agree to your request, and we may say “no” if it would affect your careservices or our legal obligation. U If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. U We will say “yes” unless a law requires us to share that information. Get a list of those with whom we’ve shared information U You can ask for a list (accounting) of the times we’ve shared your health service information for six years prior to the date you ask, who we shared it with, and why. U We will include all the disclosures except for those about treatmentservices, 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 £Ó “œ˜Ì ð 12 months. Get a copy of this privacy notice U 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 U If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health service information. U We will make sure the person has this authority and can act for you before we take any action. File a complaint if you feel your rights are violated U You can complain if you feel we have violated your rights by contacting us ÕȘ} Ì i ˆ˜vœÀ“>̈œ˜ œ˜ «>}i £° U You can file a complaint with the U.S. Department of Health and Human -iÀۈVià "vwVi vœÀ CˆÛˆ ,ˆ} Ìà LÞ Ãi˜`ˆ˜} > iÌÌiÀ ̜ Óää I˜`i«i˜`i˜Vi AÛi˜Õi] -°7°] 7>à ˆ˜}̜˜] D°C° ÓäÓä£] V>ˆ˜} £‡nÇLJșȇÈÇÇx] œÀ visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. U We will not retaliate against you for filing a complaint. œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i Ó Your Choices For certain health 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: U Share information with your family, close friends, or others involved in your care U Share information in a disaster relief situation U Include your information in a hospital directory U Contact you for fundraising efforts 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: U Marketing purposes U Sale of your information U Most sharing of psychotherapy notes In the case of fundraising: U We may contact you for fundraising efforts, but you can tell us not to contact you again. Our Uses and Disclosures How do 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 typically 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 health information? We typically use or share information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your health mind at any time. Let us know in writing if you change your mind. For more information in see: xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxxxxx/xxxxxxxxx/xxxxxxxx.xxxx. Changes to the following ways. Treat you U Terms of this Notice We can use 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 (000) 000-0000 We never market or sell personal information We will never share any service records without your health 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 share it with other professionals who are treating youHuman 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 (Participant Employer or Managing Party Name) and ___________________________________________ , Participant Employer or Managing Party.

Your Rights. You have the right to: • Get a copy of your paper or electronic medical record • Correct your paper or electronic medical record • Request confidential communication • Ask us to limit the information we share • Get a list of those with whom we’ve shared your information • Get a copy of this privacy notice • Choose someone to act for you • File a complaint if you believe your privacy rights have been violated Your Choices You have some choices in the way that we use and share information as we: • Tell family and friends about your condition • Provide disaster relief • Include you in a hospital directory • Provide mental health care • Market our services and sell your information • Raise funds Our Uses and Disclosures We may use and share your information as we: • Treat you • Run our organization • Xxxx for your services • Help with public health and safety issues • Do research • Comply with the law • Respond to organ and tissue donation requests • Work with a medical examiner or funeral director • Address workers’ compensation, law enforcement, and other government requests • Respond to lawsuits and legal actions 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 an electronic or paper copy of your medical record U • You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. U • We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee. Ask us to correct your medical record U • You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. U • We may say “no” to your request, but we’ll tell you why in writing within 60 days. Request confidential communications U • You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. U • We will say “yes” to all reasonable requests. continued on next page œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i £ Your Rights continued Ask us to limit what we use or share U • You can ask us not to use or share certain health information for treatment, payment, or our operations. U We are not required to agree to your request, and we may say “no” if it would affect your care. U • If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. U We will say “yes” unless a law requires us to share that information. • This practice is participating in the Hoag Health Information Exchange (HIE), an electronic system through which it and other participating healthcare providers can share patient information according to nationally recognized standards and in compliance with federal and state law that protects your privacy. Through the HIE, your participating providers will be able to access information about you that is necessary for your treatment, unless you choose to have your information withheld from the HIE by personally opting out from participation. If you choose to opt out of the HIE (that is, if you feel that your medical information should not be shared through the HIE), We will continue to use your medical information in accordance with this Notice of Privacy Practices and the law, but will not make it available to others through the HIE. To opt out of the HIE, please contact the Hoag Director of Health Information Exchange in writing at Xxx Xxxx Xxxxx, Newport Beach, CA 92663, or by telephone at 949/000-0000. Get a list of those with whom we’ve shared information U • 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, who we shared it with, and why. U • 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 £Ó “œ˜Ì ð 12 months. Get a copy of this privacy notice U 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 U • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. U • We will make sure the person has this authority and can act for you before we take any action. File a complaint if you feel your rights are violated U • You can complain if you feel we have violated your rights by contacting us ÕȘ} Ì i ˆ˜vœÀ“>̈œ˜ œ˜ «>}i £° U using the information on page 1. • You can file a complaint with the U.S. Department of Health and Human -iÀۈVià "vwVi vœÀ CˆÛˆ ,ˆ} Ìà LÞ Ãi˜`ˆ˜} > iÌÌiÀ ̜ Óää I˜`i«i˜`i˜Vi AÛi˜Õi] Services Office for Civil Rights by sending a letter to 000 Xxxxxxxxxxxx Xxxxxx, X.X., Xxxxxxxxxx, X.X. 00000, calling 0- 000-°7°] 7>à ˆ˜}̜˜] D°C° ÓäÓä£] V>ˆ˜} £‡nÇLJșȇÈÇÇx] œÀ 000-0000, or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. U • We will not retaliate against you for filing a complaint. œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i Ó Your Choices For certain 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: U • Share information with your family, close friends, or others involved in your care U • Share information in a disaster relief situation U • Include your information in a hospital directory U Contact you for fundraising efforts 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: U • Marketing purposes U • Sale of your information U • Most sharing of psychotherapy notes In the case of fundraising: U • We may contact you for fundraising efforts, but you can tell us not to contact you again. Our Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following ways. Treat you U We can use your health information and share it with other professionals who are treating you.

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 an electronic or paper a copy of your paper or electronic medical record U ⮚ You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. .. Ask us how to do this. U ⮚ We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee. Ask us to correct Correct your paper or electronic medical record U ⮚ You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. U ⮚ We may say “no” to your request, but we’ll tell you why in writing within 60 days. Request confidential communications U communication ⮚ You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. U ⮚ We will say “yes” to all reasonable requests. continued on next page œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i £ Your Rights continued Ask us to limit what the information we use or share U ⮚ You can ask us not to use or share certain health information for treatment, payment, or our operations. U ⮚ We are not required to agree to your request, and we may say “no” if it would affect your care. U ⮚ If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. U ⮚ We will say “yes” unless a law requires us to share that information. Get a list of those with whom we’ve we have shared your information U ⮚ 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, who we shared it with, and why. U ⮚ 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 £Ó “œ˜Ì ð 12 months. Get a copy of this privacy notice U ⮚ 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 promptly provide you with a paper copy promptlycopy. Choose someone to act for you U ⮚ If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. U ⮚ We will make sure that the person has this authority and can act for you before we take any action. File a complaint if you feel believe your privacy rights are have been violated U ⮚ You can complain if you feel that we have violated your rights by contacting us ÕȘ} Ì i ˆ˜vœÀ“>̈œ˜ œ˜ «>}i £° U using the information in this notice. ⮚ You can file a complaint with the U.S. Department of Health and Human -iÀۈVià "vwVi vœÀ CˆÛˆ ,ˆ} Ìà LÞ Ãi˜`ˆ˜} > iÌÌiÀ ̜ Óää I˜`i«i˜`i˜Vi AÛi˜Õi] Services Office for Civil Rights by sending a letter to: U.S. Department of Health and Human Services Office for Civil Rights 000 Xxxxxxxxxxxx Xxxxxx, X.X. Xxxxxxxxxx, X.X. 00000 Or by calling: 0-°7°] 7>à ˆ˜}̜˜] D°C° ÓäÓä£] V>ˆ˜} £‡nÇLJșȇÈÇÇx] œÀ 000-000-0000 or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. U xxxxx://xxx.xxx.xxx/civil-rights/filing-a-complaint/index.html ⮚ We will not retaliate against you for filing a complaint. œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i Ó Your Choices For certain 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: U Share information with your family, close friends, or others involved in your care U Share information in a disaster relief situation U Include your information in a hospital directory U Contact you for fundraising efforts 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 we never share your information unless you give us written permission: U Marketing purposes U Sale of your information U Most sharing of psychotherapy notes In the case of fundraising: U We may contact you for fundraising efforts, but you can tell us not to contact you again. Our Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following ways. Treat you U We can use your health information and share it with other professionals who are treating you.

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 an electronic or paper copy of your medical record U You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. U We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-cost- based fee.  Ask us to correct your medical record U You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. U We may say “no” to your request, but we’ll tell you why in writing within 60 days.  Request confidential communications U You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. U We will say “yes” to all reasonable requests. continued on next page œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i £ Your Rights continued  Ask us to limit what we use or share U You can ask us not to use or share certain health information for treatment, payment, or our operations. U We are not required to agree to your request, and we may say “no” if it would affect your care. U If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. U We will say “yes” unless a law requires us to share that information.  Get a list of those with whom we’ve shared information U 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, who we shared it with, and why. U 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 £Ó “œ˜Ì ð 12 months.  Get a copy of this privacy notice U 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 U If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. U We will make sure the person has this authority and can act for you before we take any action.  File a complaint if you feel your rights are violated U You can complain if you feel we have violated your rights by contacting us ÕȘ} Ì i ˆ˜vœÀ“>̈œ˜ œ˜ «>}i £° U You can file a complaint with the U.S. Department of Health and Human -iÀۈVià "vwVi vœÀ CˆÛˆ ,ˆ} Ìà LÞ Ãi˜`ˆ˜} > iÌÌiÀ ̜ Óää I˜`i«i˜`i˜Vi AÛi˜Õi] -°7°] 7>à ˆ˜}̜˜] D°C° ÓäÓä£] V>ˆ˜} £‡nÇLJșȇÈÇÇx] œÀ visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. U We will not retaliate against you Services Office for filing a complaint. œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i Ó Your Choices For certain 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: U Share information with your family, close friends, or others involved in your care U Share information in a disaster relief situation U Include your information in a hospital directory U Contact you for fundraising efforts 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 we never share your information unless you give us written permission: U Marketing purposes U Sale of your information U Most sharing of psychotherapy notes In the case of fundraising: U We may contact you for fundraising efforts, but you can tell us not to contact you again. Our Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following ways. Treat you U We can use your health information and share it with other professionals who are treating you.Civil Rights by:

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 an electronic or paper copy of your medical record U ● You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. U ● We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee. Ask us to correct your medical record U ● You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. U ● We may say “no” to your request, but we’ll tell you why in writing within 60 days. Request confidential communications U ● You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. U ● We will say “yes” to all reasonable requests. continued on next page œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i £ Your Rights continued Ask us to limit what we use or share U ● You can ask us not to use or share certain health information for treatment, payment, or our operations. U ○ We are not required to agree to your request, and we may say “no” if it would affect your care. U ● If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. U ○ We will say “yes” unless a law requires us to share that information. Get a list of those with whom we’ve shared information U ● 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, who we shared it with, and why. U ● 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 £Ó “œ˜Ì ð 12 months. Get a copy of this privacy notice U ● 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 U ● If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. U ● We will make sure the person has this authority and can act for you before we take any action. File a complaint if you feel your rights are violated U ● You can complain if you feel we have violated your rights by contacting us ÕȘ} Ì i ˆ˜vœÀ“>̈œ˜ œ˜ «>}i £° U using the information on page 1. ● You can file a complaint with the U.S. Department of Health and Human -iÀۈVià "vwVi vœÀ CˆÛˆ ,ˆ} Ìà LÞ Ãi˜`ˆ˜} > iÌÌiÀ ̜ Óää I˜`i«i˜`i˜Vi AÛi˜Õi] Services Offi e for Civil Rights by sending a letter to 000 Xxxxxxxxxxxx Xxxxxx, X.X., Xxxxxxxxxx, X.X. 00000, calling 0-°7°] 7>à ˆ˜}̜˜] D°C° ÓäÓä£] V>ˆ˜} £‡nÇLJșȇÈÇÇx] œÀ 000-000-0000, or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. U ● If you have concerns about the safety and/or quality of care provide by our organization please follow this link to make a report to the Joint Commission (https: /xxx.xxxxxxxxxxxxxxx.xxx/xxxxxx_x_xxxxxxxxx.xxxx). ● We will not retaliate against you for filing a complaint. œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i Ó Your Choices For certain 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: U ● Share information with your family, close friends, or others involved in your care U ● Share information in a disaster relief situation U ● Include your information in a hospital directory U ● Contact you for fundraising efforts 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 we never share your information unless you give us written permission: U ● Marketing purposes U ● Sale of your information U ● Most sharing of psychotherapy notes In the case of fundraising: U ● We may contact you for fundraising efforts, but you can tell us not to contact you again. Our Uses and Disclosures ● How do we typically use or share your health information? We typically use or share your health information in the following ways. Treat you U ● We can use your health information and share it with other professionals who are treating you.

Your Rights. You have the right to: • Get a copy of your paper or electronic medical record • Correct your paper or electronic medical record • Request confidential communication • Ask us to limit the information we share • Get a list of those with whom we’ve shared your information • Get a copy of this privacy notice • Choose someone to act for you • File a complaint if you believe your privacy rights have been violated Your Choices You have some choices in the way that we use and share information as we: • Tell family and friends about your condition • Provide disaster relief • Include you in a hospital directory • Provide mental health care • Market our services and sell your information • Raise funds Our Uses and Disclosures We may use and share your information as we: • Treat you • Run our organization • Xxxx for your services • Help with public health and safety issues • Do research • Comply with the law • Respond to organ and tissue donation requests • Work with a medical examiner or funeral director • Address workers’ compensation, law enforcement, and other government requests • Respond to lawsuits and legal actions 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 an electronic or paper copy of your medical record U • You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. U • We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee. Ask us to correct your medical record U • You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. U • We may say “no” to your request, but we’ll tell you why in writing within 60 days. Request confidential communications U • You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. U • We will say “yes” to all reasonable requests. continued on next page œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i £ Your Rights continued Ask us to limit what we use or share U • You can ask us not to use or share certain health information for treatment, payment, or our operations. U We are not required to agree to your request, and we may say “no” if it would affect your care. U • If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. U We will say “yes” unless a law requires us to share that information. Get a list of those with whom we’ve shared information U • 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, who we shared it with, and why. U • 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 £Ó “œ˜Ì ð 12 months. Get a copy of this privacy notice U 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 U • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. U • We will make sure the person has this authority and can act for you before we take any action. File a complaint if you feel your rights are violated U • You can complain if you feel we have violated your rights by contacting us ÕȘ} Ì i ˆ˜vœÀ“>̈œ˜ œ˜ «>}i £° U using the information provided. • You can file a complaint with the U.S. Department of Health and Human -iÀۈVià "vwVi vœÀ CˆÛˆ ,ˆ} Ìà LÞ Ãi˜`ˆ˜} > iÌÌiÀ ̜ Óää I˜`i«i˜`i˜Vi AÛi˜Õi] Services Office for Civil Rights by sending a letter to 000 Xxxxxxxxxxxx Xxxxxx, X.X., Xxxxxxxxxx, X.X. 00000, calling 0-°7°] 7>à ˆ˜}̜˜] D°C° ÓäÓä£] V>ˆ˜} £‡nÇLJșȇÈÇÇx] œÀ 000-000-0000, or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. U • We will not retaliate against you for filing a complaint. œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i Ó Your Choices For certain 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: U • Share information with your family, close friends, or others involved in your care U • Share information in a disaster relief situation U • Include your information in a hospital directory U Contact you for fundraising efforts 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 we never share your information unless you give us written permission: U • Marketing purposes U • Sale of your information U • Most sharing of psychotherapy notes In the case of fundraising: U • We may contact you for fundraising efforts, but you can tell us not to contact you again. Our Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following ways. Treat you U We can use your health information and share it with other professionals who are treating you.

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 an electronic or paper copy of your medical record U • You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. U • We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee. Ask us to correct your medical record U • You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. U • We may say “no” to your request, but we’ll tell you why in writing within 60 days. Request confidential communications U • You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. U • We will say “yes” to all reasonable requests. continued on next page œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i £ Your Rights continued Ask us to limit what we use or share U • You can ask us not to use or share certain health information for treatment, payment, or our operations. U We are not required to agree to your request, and we may say “no” if it would affect your care. U • If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. U We will say “yes” unless a law requires us to share that information. Get a list of those with whom we’ve shared information U • 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, who we shared it with, and why. U • 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 £Ó “œ˜Ì ð Get a copy of this privacy notice U 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 promptly12 months. Choose someone to act for you U • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. U • We will make sure the person has this authority and can act for you before we take any action. File a complaint if you feel your rights are violated U • You can complain if you feel we have violated your rights by contacting us ÕȘ} Ì i ˆ˜vœÀ“>̈œ˜ œ˜ «>}i £° U using the information on page 1. • You can file a complaint with the U.S. Department of Health and Human -iÀۈVià "vwVi vœÀ CˆÛˆ ,ˆ} Ìà LÞ Ãi˜`ˆ˜} > iÌÌiÀ ̜ Óää I˜`i«i˜`i˜Vi AÛi˜Õi] Services Office for Civil Rights by sending a letter to 000 Xxxxxxxxxxxx Xxxxxx, X.X., Xxxxxxxxxx, X.X. 00000, calling 0-°7°] 7>à ˆ˜}̜˜] D°C° ÓäÓä£] V>ˆ˜} £‡nÇLJșȇÈÇÇx] œÀ 000-000-0000, or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. U • We will not retaliate against you for filing a complaint. œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i Ó Your Choices For certain 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: U • Share information with your family, close friends, or others involved in your care U • Share information in a disaster relief situation U • Include your information in a hospital directory U Contact you for fundraising efforts 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 we never share your information unless you give us written permission: U • Marketing purposes U • Sale of your information U • Most sharing of psychotherapy notes In the case of fundraising: U We may contact you for fundraising efforts, but you can tell us not to contact you again. Our Uses and Disclosures Disclosure How do we typically use or share your health information? We typically use or share your health information in the following ways. Treat you U • We can use your health information and share it with other professionals who are treating you.

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 an electronic or paper copy of your medical record U You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. U We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee. Ask us to correct your medical record U You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. U We may say “no” to your request, but we’ll tell you why in writing within 60 days. Request confidential communications U You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. U We will say “yes” to all reasonable requests. continued on next page œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i £ Your Rights continued Ask us to limit what we use or share U You can ask us not to use or share certain health information for treatment, payment, or our operations. U We are not required to agree to your request, and we may say “no” if it would affect your care. U If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. U We will say “yes” unless a law requires us to share that information. Get a list of those with whom we’ve shared information U 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, who we shared it with, and why. U 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 £Ó “œ˜Ì ð Get a copy of this privacy notice U 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 U If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. U We will make sure the person has this authority and can act for you before we take any action. File a complaint if you feel your rights are violated U You can complain if you feel we have violated your rights by contacting us ÕȘ} Ì i ˆ˜vœÀ“>̈œ˜ œ˜ «>}i £° U You can file a complaint with the U.S. Department of Health and Human -iÀۈVià "vwVi vœÀ CˆÛˆ ,ˆ} Ìà LÞ Ãi˜`ˆ˜} > iÌÌiÀ ̜ Óää I˜`i«i˜`i˜Vi AÛi˜Õi] -°7°] 7>à ˆ˜}̜˜] D°C° ÓäÓä£] V>ˆ˜} £‡nÇLJșȇÈÇÇx] œÀ visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. U We will not retaliate against you for filing a complaint. œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i Ó Your Choices For certain 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: U Share information with your family, close friends, or others involved in your care U Share information in a disaster relief situation U Include your information in a hospital directory U Contact you for fundraising efforts 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 we never share your information unless you give us written permission: U Marketing purposes U Sale of your information U Most sharing of psychotherapy notes In the case of fundraising: U We may contact you for fundraising efforts, but you can tell us not to contact you again. Our Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following ways. Treat you U We can use your health information and share it with other professionals who are treating you.

Your Rights. You have the right to: • Get a copy of your paper or electronic medical record • Correct your paper or electronic medical record • Request confidential communication • Ask us to limit the information we share • Get a list of those with whom we’ve shared your information • Get a copy of this privacy notice • Choose someone to act for you • File a complaint if you believe your privacy rights have been violated Your Choices You have some choices in the way that we use and share information as we: • Tell family and friends about your condition • Provide disaster relief • Include you in a hospital directory • Provide mental health care • Market our services and sell your information • Raise funds Our Uses and Disclosures We may use and share your information as we: • Treat you • Run our organization • Bill for your services • Help with public health and safety issues • Do research • Comply with the law • Respond to organ and tissue donation requests • Work with a medical examiner or funeral director • Address workers’ compensation, law enforcement, and other government requests • Respond to lawsuits and legal actions 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 an electronic or paper copy of your medical record U • You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. U • We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee. Ask us to correct your medical record U • You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. U • We may say “no” to your request, but we’ll tell you why in writing within 60 days. • Request confidential communications U • You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. U • We will say “yes” to all reasonable requests. continued on next page œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i £ Your Rights continued Ask us to limit what we use or share U • You can ask us not to use or share certain health information for treatment, payment, or our operations. U We are not required to agree to your request, and we may say “no” if it would affect your care. U • If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. U We will say “yes” unless a law requires us to share that information. Get a list of those with whom we’ve shared information U • 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, who we shared it with, and why. U • 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 £Ó “œ˜Ì ð 12 months. Get a copy of this privacy notice U 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 U • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. U • We will make sure the person has this authority and can act for you before we take any action. File a complaint if you feel your rights are violated U • You can complain if you feel we have violated your rights by contacting us ÕȘ} Ì i ˆ˜vœÀ“>̈œ˜ œ˜ «>}i £° U at Arizona Psychology and Wellness 0000 X Xxxxx Xx XXX 000 Xxxxxxx, XX 00000, calling 000-000-0000, or emailing at xxxxx@xxxxxxxxxxxxxxxxx.xxx You may also contact the Ethics Committee of the Arizona Psychological Association (AzPA) for further information. • You can file a complaint with the U.S. Department of Health and Human -iÀۈVià "vwVi vœÀ CˆÛˆ ,ˆ} Ìà LÞ Ãi˜`ˆ˜} > iÌÌiÀ ̜ Óää I˜`i«i˜`i˜Vi AÛi˜Õi] Services Office for Civil Rights by sending a letter to 000 Xxxxxxxxxxxx Xxxxxx, X.X., Xxxxxxxxxx, X.X. 00000, calling 0- 000-°7°] 7>à ˆ˜}̜˜] D°C° ÓäÓä£] V>ˆ˜} £‡nÇLJșȇÈÇÇx] œÀ 000-0000, or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. U • We will not retaliate against you for filing a complaint. œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i Ó Your Choices For certain 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: U • Share information with your family, close friends, or others involved in your care U • Share information in a disaster relief situation U • Include your information in a hospital directory U Contact you for fundraising efforts 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: U • Marketing purposes U • Sale of your information U • Most sharing of psychotherapy notes In the case of fundraising: U We may contact you for fundraising efforts, but you can tell us not to contact you again. Our Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following ways. Treat you U 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. How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxxxxx/xxxxxxxxx/xxxxx. html Help with public health and safety issues We 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 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. Respond to organ and tissue donation requests We can share health information about you with organ procurement organizations. 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 workers’ compensation claims • For law enforcement purposes or with a law enforcement official • With health oversight agencies for activities authorized by law • For special government functions such as military, national security, and presidential protective services Respond to lawsuits and legal actions We can share 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 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/xxxxxxx p. html. 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 web site. This notice went into effect on March 1, 2017. Arizona Psychology and Wellness 0000 X Xxxxx Xx, Xxxx 0, Xxxxx 000, Xxxxxxx, XX 00000-0000 o: (000)000-0000 f: (000)000-0000 xxxx://xxx.XxxxxxxXxxxxxxxxx.xxx Please sign and return after reading the Psychologist-Patient Agreement and the HIPPA Notice above. Pages 1-8 are yours to keep for your reference.

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 an electronic or paper copy of your medical record U • You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. U • We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee. Ask us to correct your medical record U • You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. U • We may say “no” to your request, but we’ll tell you why in writing within 60 days. Request confidential communications U • You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. U • We will say “yes” to all reasonable requests. continued on next page œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i £ Your Rights continued Ask us to limit what we use or share U • You can ask us not to use or share certain health information for treatment, payment, or our operations. U • We are not required to agree to your request, and we may say “no” if it would affect your care. U • If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. U • We will say “yes” unless a law requires us to share that information. Get a list of those with whom we’ve shared information U • 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, who we shared it with, and why. U • 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 £Ó “œ˜Ì ð 12 months. Get a copy of this privacy notice U • 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 U • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. U • We will make sure the person has this authority and can act for you before we take any action. File a complaint if you feel your rights are violated U • You can complain if you feel we have violated your rights by contacting us ÕȘ} Ì i ˆ˜vœÀ“>̈œ˜ œ˜ «>}i £° U using the information on page 1. • You can file a complaint with the U.S. Department of Health and Human -iÀۈVià "vwVi vœÀ CˆÛˆ ,ˆ} Ìà LÞ Ãi˜`ˆ˜} > iÌÌiÀ ̜ Óää I˜`i«i˜`i˜Vi AÛi˜Õi] Services Office for civil Rights by sending a letter to 000 Xxxxxxxxxxxx Xxxxxx, X.X., Xxxxxxxxxx, X.x. 00000, calling 0-°7°] 7>à ˆ˜}̜˜] D°C° ÓäÓä£] V>ˆ˜} £‡nÇLJșȇÈÇÇx] œÀ 000-000-0000, or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. U • We will not retaliate against you for filing a complaint. œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i Ó Your Choices For certain 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: U • Share information with your family, close friends, or others involved in your care U • Share information in a disaster relief situation U • Include your information in a hospital directory U • Contact you for fundraising efforts 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 we never share your information unless you give us written permission: U • Marketing purposes U • Sale of your information U • Most sharing of psychotherapy notes In the case of fundraising: U • We may contact you for fundraising efforts, but you can tell us not to contact you again. Our Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following ways. Treat you U • We can use your health information and share it with other professionals who are treating you.

Your Rights. You have the right to: • Get a copy of your paper or electronic service record • Correct your paper or electronic service record • Request confidential communication • Ask us to limit the information we share • Get a list of those with whom we’ve shared your information • Get a copy of this privacy notice • Choose someone to act for you • File a complaint if you believe your privacy rights have been violated Your Choices You have some choices in the way that we use and share information as we: • Discuss your services with family, friends and caregivers • Provide disaster relief • Provide services • Market our services Our Uses and Disclosures We may use and share your information as we: • Serve you • Run our organization • Bill for your services • Help with public health and safety issues • Comply with the law • Respond to required county, state and federal program requests • Address workers’ compensation, law enforcement, and other government requests • Respond to lawsuits and legal actions 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 an electronic or paper copy of your medical service record U • You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. U • We will provide a copy or a summary of your health service information, usually within 30 days of your request. We may charge a reasonable, cost-based fee. Ask us to correct your medical service record U • You can ask us to correct health any information about you that you think is incorrect or incomplete. Ask us how to do this. U • We may say “no” to your request, but we’ll tell you why in writing within 60 days. Request confidential communications U • You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. U • We will say “yes” to all reasonable requests. continued on next page œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i £ Your Rights continued Ask us to limit what we use or share U • You can ask us not to use or share certain health information for treatmentservices, payment, or our operations. U We are not required to agree to your request, and we may say “no” if it would affect your careservices or our legal obligation. U • If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. U We will say “yes” unless a law requires us to share that information. Get a list of those with whom we’ve shared information U • You can ask for a list (accounting) of the times we’ve shared your health service information for six years prior to the date you ask, who we shared it with, and why. U • We will include all the disclosures except for those about treatmentservices, 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 £Ó “œ˜Ì ð 12 months. Get a copy of this privacy notice U 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 U • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health service information. U • We will make sure the person has this authority and can act for you before we take any action. File a complaint if you feel your rights are violated U You can complain if you feel we have violated your rights by contacting us ÕȘ} Ì i ˆ˜vœÀ“>̈œ˜ œ˜ «>}i £° U You can file a complaint with the U.S. Department of Health and Human -iÀۈVià "vwVi vœÀ CˆÛˆ ,ˆ} Ìà LÞ Ãi˜`ˆ˜} > iÌÌiÀ ̜ Óää I˜`i«i˜`i˜Vi AÛi˜Õi] -°7°] 7>à ˆ˜}̜˜] D°C° ÓäÓä£] V>ˆ˜} £‡nÇLJșȇÈÇÇx] œÀ visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. U We will not retaliate against you for filing a complaint. œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i Ó Your Choices For certain 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: U Share information with your family, close friends, or others involved in your care U Share information in a disaster relief situation U Include your information in a hospital directory U Contact you for fundraising efforts 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 we never share your information unless you give us written permission: U Marketing purposes U Sale of your information U Most sharing of psychotherapy notes In the case of fundraising: U We may contact you for fundraising efforts, but you can tell us not to contact you again. Our Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following ways. Treat you U We can use your health information and share it with other professionals who are treating you.

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 an electronic or paper copy of your medical record U • You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. U • We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee. Ask us to correct your medical record U • You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. U • We may say “no” to your request, but we’ll tell you why in writing within 60 days. Request confidential communications U • You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. U • We will say “yes” to all reasonable requests. continued on next page œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i £ Your Rights continued Ask us to limit what we use or share U • You can ask us not to use or share certain health information for treatment, payment, or our operations. U • We are not required to agree to your request, and we may say “no” if it would affect your care. U • If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. U • We will say “yes” unless a law requires us to share that information. Get a list of those with whom we’ve shared information U • 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, who we shared it with, and why. U • 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 £Ó “œ˜Ì ð 12 months. Get a copy of this privacy notice U • 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 U • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. U • We will make sure the person has this authority and can act for you before we take any action. .File a complaint if you feel your rights are violated U • You can complain if you feel we have violated your rights by contacting us ÕȘ} Ì i ˆ˜vœÀ“>̈œ˜ œ˜ «>}i £° U using the information on page 1. • You can file a complaint with the U.S. Department of Health and Human -iÀۈVià "vwVi vœÀ CˆÛˆ ,ˆ} Ìà LÞ Ãi˜`ˆ˜} > iÌÌiÀ ̜ Óää I˜`i«i˜`i˜Vi AÛi˜Õi] Services Office for Civil Rights by sending a letter to 000 Xxxxxxxxxxxx Xxxxxx, X.X., Xxxxxxxxxx, X.X. 00000, calling 0-°7°] 7>à ˆ˜}̜˜] D°C° ÓäÓä£] V>ˆ˜} £‡nÇLJșȇÈÇÇx] œÀ 000-000-0000, or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. U • We will not retaliate against you for filing a complaint. œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i Ó Your Choices For certain 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: U • Share information with your family, close friends, or others involved in your care U • Share information in a disaster relief situation U • Include your information in a hospital directory U • Contact you for fundraising efforts 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 we never share nevershare your information unless you give us written permission: U • Marketing purposes U • Sale of your information U • Most sharing of psychotherapy notes In the case of fundraising: U • We may contact you for fundraising efforts, but you can tell us not to contact you again. Our Uses and Disclosures How xxxxx.Xxx do we typically use or share your health information? We typically use or share your health information in the following ways. Treat you U • We can use your health information and share it with other professionals who are treating you. Example: A doctor treating you or 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.

Your Rights. You have the right to: - Get a copy of your paper or electronic medical record - Correct inaccuracies in your paper or electronic medical record - Request confidential communication - Ask us to limit the information we share - Get a list of those with whom we have shared your information - Get a copy of this privacy notice - Choose someone to act for you - File a complaint if you believe your privacy rights have been violated Our Uses and Disclosures: We may use and share your information as we: - Fill your exercise prescription - Run our organization - Bill for your services - Help with public health and safety issues - Do research - Comply with the law - Address workers’ compensation, law enforcement, and other government requests - Respond to lawsuits and legal actions - We never market or sell personal information 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 an electronic or paper copy of your medical record U - You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. U - We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee. Ask us to correct your medical record U - You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. U - We may say “no” to deny your request, but we’ll we will tell you why in writing within 60 days. Request confidential communications U - You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. U - We will say “yes” agree to all reasonable requests. continued on next page œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i £ Your Rights continued Ask us to limit what we use or share U - You can ask us not to use or share certain health information for treatment, payment, or our operations. U We are not required to agree to your request, and we may say “no” deny your request if it would affect your care. U - If you pay for a service or a health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. U We will say “yes” agree unless a law requires us to share that information. Get a list of those with whom we’ve shared information U - 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, who we shared it with, and why. U - 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 We will provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within £Ó “œ˜Ì ð 12 months. Get a copy of this privacy notice U - 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 U - If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. U - We will make sure the person has this authority and can act for you before we take any action. File a complaint if you feel your rights are violated U - You can complain if you feel we have violated your rights by contacting us ÕȘ} Ì i ˆ˜vœÀ“>̈œ˜ œ˜ «>}i £° U You can file a complaint with using the U.S. Department of Health and Human -iÀۈVià "vwVi vœÀ CˆÛˆ ,ˆ} Ìà LÞ Ãi˜`ˆ˜} > iÌÌiÀ ̜ Óää I˜`i«i˜`i˜Vi AÛi˜Õi] -°7°] 7>à ˆ˜}̜˜] D°C° ÓäÓä£] V>ˆ˜} £‡nÇLJșȇÈÇÇx] œÀ visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. U We will not retaliate against you for filing a complaintinformation on Page . œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i Ó Your Choices For certain 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: U - Share information with your family, close friends, or others involved in your care U - Share information in a disaster relief situation U Include your information in a hospital directory U Contact you for fundraising efforts If you are not able to tell us your our preference, for example if you are unconscious, we may go ahead and still 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 we never share your information unless you give us written permission: U Marketing permission to so. Such may include marketing purposes U Sale of your information U Most sharing of psychotherapy notes In the case of fundraising: U We may contact you for fundraising efforts, but you can tell us not to contact you againor testimonials. Our Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following waysways and you hereby consent to such use. Treat To treat you U - 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. To run our organization - We can use and share your health information to run our business, improve your care, and contact you when necessary. - Example: We use health information about you to management your treatment and services. To bill for our 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 contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: - xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxxxxx/xxxxxxxxx/xxxxx.xxxx. To help with public health and safety issues - We can share health information about you for certain situations such as: o Preventing disease o Helping with product recalls o Reporting adverse reactions to medications o Reporting suspected abuse, neglect, or domestic violence o Preventing or reducing a serious threat to anyone’s health or safety To do research - We can use or share your information for health research To 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. To address workers’ compensation, law enforcement, and other government requests - We can use or share health information about you: o For workers’ compensation claims o For law enforcement purposes or with a law enforcement official o With health oversight agencies for activities authorized by law o For special government functions such as military, national security, and presidential protective services. Reviewed/Revised: I understand my signature requests that payment be made and authorizes release of medical information necessary to pay claim. If “other health insurance” is indicated on the HCFA-1500 form, or elsewhere on other approved forms or electronically submitted claims, my signature authorizes release of information to the insurer or agency shown. Authorization to Photograph I hereby consent to be photographed while receiving care and authorize Redline Exercise Rx staff to obtain photographs for the purposes of identification and to provide documentation of my medical condition including any wound monitoring, healing progress or failure to heal. I understand that any photographs taken will be placed in and remain part of my medical record and will be viewed only by those individuals involved in providing my care. The term “photograph” includes photography in digital or any other format and any other means of recording or reproducing images. Statement of Client Right and Responsibilities and Notice of Privacy Practices and Privacy Rights I certify that I have read, received a copy of and understand the Statement of Client Rights and Responsibilities that has been explained to me orally by a representative of Redline Exercise Rx. I acknowledge that I have received a copy of the privacy documents. I understand that this document provides an explanation of the ways in which my health information may be used or disclosed by Redline Exercise Rx and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information. If I am a Medicare or Medicaid patient/client, I certify that I have received a copy of CMS’s Statement or Privacy Rights. I have also received the complaint process and grievance plan, qualifying criteria for Medicare Benefits, Emergency and Disaster Plans, Home Safety Guidelines, Fall Assessment Prevention Plan, Medication Safety, Food and Medication Interactions, Care of Home Chart and Confidentiality.

Your Rights. You have the right to: - Get a copy of your paper or electronic medical record - Correct inaccuracies in your paper or electronic medical record - Request confidential communication - Ask us to limit the information we share - Get a list of those with whom we have shared your information - Get a copy of this privacy notice - Choose someone to act for you - File a complaint if you believe your privacy rights have been violated Our Uses and Disclosures: We may use and share your information as we: - Fill your exercise prescription - Run our organization - Xxxx for your services - Help with public health and safety issues - Do research - Comply with the law - Address workers’ compensation, law enforcement, and other government requests - Respond to lawsuits and legal actions - We never market or sell personal information 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 an electronic or paper copy of your medical record U - You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. U - We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee. Ask us to correct your medical record U - You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. U - We may say “no” to deny your request, but we’ll we will tell you why in writing within 60 days. Request confidential communications U - You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. U - We will say “yes” agree to all reasonable requests. continued on next page œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i £ Your Rights continued Ask us to limit what we use or share U - You can ask us not to use or share certain health information for treatment, payment, or our operations. U We are not required to agree to your request, and we may say “no” deny your request if it would affect your care. U - If you pay for a service or a health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. U We will say “yes” agree unless a law requires us to share that information. Get a list of those with whom we’ve shared information U - 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, who we shared it with, and why. U - 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 We will provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within £Ó “œ˜Ì ð 12 months. Get a copy of this privacy notice U - 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 U - If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. U - We will make sure the person has this authority and can act for you before we take any action. File a complaint if you feel your rights are violated U - You can complain if you feel we have violated your rights by contacting us ÕȘ} Ì i ˆ˜vœÀ“>̈œ˜ œ˜ «>}i £° U You can file a complaint with using the U.S. Department of Health and Human -iÀۈVià "vwVi vœÀ CˆÛˆ ,ˆ} Ìà LÞ Ãi˜`ˆ˜} > iÌÌiÀ ̜ Óää I˜`i«i˜`i˜Vi AÛi˜Õi] -°7°] 7>à ˆ˜}̜˜] D°C° ÓäÓä£] V>ˆ˜} £‡nÇLJșȇÈÇÇx] œÀ visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. U We will not retaliate against you for filing a complaintinformation on Page . œÌˆVi œv *ÀˆÛ>VÞ *À>V̈Vià U *>}i Ó Your Choices For certain 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: U - Share information with your family, close friends, or others involved in your care U - Share information in a disaster relief situation U Include your information in a hospital directory U Contact you for fundraising efforts If you are not able to tell us your our preference, for example if you are unconscious, we may go ahead and still 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 we never share your information unless you give us written permission: U Marketing permission to so. Such may include marketing purposes U Sale of your information U Most sharing of psychotherapy notes In the case of fundraising: U We may contact you for fundraising efforts, but you can tell us not to contact you againor testimonials. Our Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following waysways and you hereby consent to such use. Treat To treat you U - 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. To run our organization - We can use and share your health information to run our business, improve your care, and contact you when necessary. - Example: We use health information about you to management your treatment and services. To xxxx for our services - We can use and share your health information to xxxx 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 contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: - xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxxxxx/xxxxxxxxx/xxxxx.xxxx. To help with public health and safety issues - We can share health information about you for certain situations such as: o Preventing disease o Helping with product recalls o Reporting adverse reactions to medications o Reporting suspected abuse, neglect, or domestic violence o Preventing or reducing a serious threat to anyone’s health or safety To do research - We can use or share your information for health research To 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. To address workers’ compensation, law enforcement, and other government requests - We can use or share health information about you: o For workers’ compensation claims o For law enforcement purposes or with a law enforcement official o With health oversight agencies for activities authorized by law o For special government functions such as military, national security, and presidential protective services. Reviewed/Revised: I understand my signature requests that payment be made and authorizes release of medical information necessary to pay claim. If “other health insurance” is indicated on the HCFA-1500 form, or elsewhere on other approved forms or electronically submitted claims, my signature authorizes release of information to the insurer or agency shown. Authorization to Photograph I hereby consent to be photographed while receiving care and authorize Redline Exercise Rx staff to obtain photographs for the purposes of identification and to provide documentation of my medical condition including any wound monitoring, healing progress or failure to heal. I understand that any photographs taken will be placed in and remain part of my medical record and will be viewed only by those individuals involved in providing my care. The term “photograph” includes photography in digital or any other format and any other means of recording or reproducing images. Statement of Client Right and Responsibilities and Notice of Privacy Practices and Privacy Rights I certify that I have read, received a copy of and understand the Statement of Client Rights and Responsibilities that has been explained to me orally by a representative of Redline Exercise Rx. I acknowledge that I have received a copy of the privacy documents. I understand that this document provides an explanation of the ways in which my health information may be used or disclosed by Redline Exercise Rx and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information. If I am a Medicare or Medicaid patient/client, I certify that I have received a copy of CMS’s Statement or Privacy Rights. I have also received the complaint process and grievance plan, qualifying criteria for Medicare Benefits, Emergency and Disaster Plans, Home Safety Guidelines, Fall Assessment Prevention Plan, Medication Safety, Food and Medication Interactions, Care of Home Chart and Confidentiality.