Common use of Changes to the Terms of this Notice Clause in Contracts

Changes to the Terms of this Notice. This notice is effective 11/6/2019. We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site. 00000 Xxxxx Xxxx • St. Louis, MO • 00000-0000 000-000-0000 Phone • 000-000-0000 Fax xxxx@xxxxxxxxxxxxxxxxx.xxx • xxx.xxxxxxxxxxxxxxxxx.xxx This is to acknowledge that I have received Care and Counseling’s Privacy Notice Name Signature Date 00000 Xxxxx Xxxx • St. Louis, MO • 00000-0000 000-000-0000 Phone • 000-000-0000 Fax xxxx@xxxxxxxxxxxxxxxxx.xxx • xxx.xxxxxxxxxxxxxxxxx.xxx Appointment Reminders Care and Counseling offers the option to receive an appointment reminder the day prior to your scheduled appointment by email (up to 2 email addresses) and/or by phone (only 1 phone number permitted). If you choose the reminder by phone, you have the option of a text message or a computer-generated voice message. Please select ONE of the following options: PHONE REMINDER (only one type of phone reminder can be provided): Text Message: I authorize Care and Counseling to send text message appointment reminders to me on my provided cell phone number. Text message charges from my cell phone provider may apply. Example of text message: “Do not reply-reminder-You have an appointment MON 01/11 at 4:00 PM – If you have any questions please call us at (000) 000-0000 – Name of Counselor Cell phone number to send text messages to: ( ) -

Changes to the Terms of this Notice. This notice is effective 11/6/2019. We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site. Notice of Privacy Practices (Rev. 11/6/2019) 2 00000 Xxxxx Xxxx • St. Louis, MO • 00000-0000 000-000-0000 Phone • 000-000-0000 Fax xxxx@xxxxxxxxxxxxxxxxx.xxx • xxx.xxxxxxxxxxxxxxxxx.xxx This is to acknowledge that I have received Care and Counseling’s Privacy Notice Name Signature Date 00000 Xxxxx Xxxx • St. Louis, MO • 00000-0000 000-000-0000 Phone • 000-000-0000 Fax xxxx@xxxxxxxxxxxxxxxxx.xxx • xxx.xxxxxxxxxxxxxxxxx.xxx Appointment Reminders APPOINTMENT REMINDERS Care and Counseling offers is now offering the option to for “Appointment Reminders.” You can receive an appointment reminder the day prior to your scheduled appointment by email (up to 2 email addresses) and/or by cell phone (only 1 phone number permitted). If you choose the reminder by phone, you have the option of via a text message message), your email address, or your phone (via a computer-computer generated voice message) the day before your scheduled appointment. Please select ONE of the following options: PHONE REMINDER (only one type of phone reminder can be provided): Text Message: I authorize Care and Counseling to send text message appointment reminders to me on my provided cell phone number. Text message charges from my cell phone provider may apply. Example of text message: “Do not reply-reminder-You have an appointment MON 01/11 at 4:00 PM – If you have any questions please call us at (000) 000-0000 – Name of Counselor Cell phone number to send text messages to: ( ) - Email message: I authorize Care and Counseling to send an email message appointment reminders to me on my provided email address. Example of email message from XxxxxxXxxxXxxxxxxx@xxxxxxxxXxxxxxx.xxx Hello, This is a reminder of your appointment on Monday – 01/11/2016 scheduled for 4:00 PM with Name of Counselor. If you have any questions regarding your appointment, please feel free to contact us at: (000) 000-0000. Thank you. Email address to send reminder messages to: Automated Voice Messages: I authorize Care and Counseling to send computer generated voice phone message appointment reminders to me on my provided phone number.

Changes to the Terms of this Notice. This notice is effective 11/6/2019. We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site. 00000 Xxxxx Xxxx • St. Louis, MO • 00000-0000 000-000-0000 Phone • 000-000-0000 Fax xxxx@xxxxxxxxxxxxxxxxx.xxx • xxx.xxxxxxxxxxxxxxxxx.xxx This is to acknowledge that I have received Care and Counseling’s Privacy Notice Name Signature Date 00000 Xxxxx Xxxx • St. Louis, MO • 00000-0000 000-000-0000 Phone • 000-000-0000 Fax xxxx@xxxxxxxxxxxxxxxxx.xxx • xxx.xxxxxxxxxxxxxxxxx.xxx Appointment Reminders Care and Counseling offers is now offering the option to for “Appointment Reminders.” You can receive an appointment reminder the day prior to your scheduled appointment by email (up to 2 email addresses) and/or by cell phone (only 1 phone number permitted). If you choose the reminder by phone, you have the option of via a text message message), your email address, or your phone (via a computer-computer generated voice message) the day before your scheduled appointment. Please select ONE of the following options: PHONE REMINDER (only one type of phone reminder can be provided): Text Message: I authorize Care and Counseling to send text message appointment reminders to me on my provided cell phone number. Text message charges from my cell phone provider may apply. Example of text message: “Do not reply-reminder-You have an appointment MON 01/11 at 4:00 PM – If you have any questions please call us at (000) 000-0000 – Name of Counselor Cell phone number to send text messages to: ( ) - Email message: I authorize Care and Counseling to send an email message appointment reminders to me on my provided email address. Example of email message from XxxxxxXxxxXxxxxxxx@xxxxxxxxXxxxxxx.xxx Hello, This is a reminder of your appointment on Monday – 01/11/2016 scheduled for 4:00 PM with Name of Counselor. If you have any questions regarding your appointment, please feel free to contact us at: (000) 000-0000. Thank you. Email address to send reminder messages to: Automated Voice Messages: I authorize Care and Counseling to send computer generated voice phone message appointment reminders to me on my provided phone number.

Changes to the Terms of this Notice. This notice is effective 11/6/2019. We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site. Notice of Privacy Practices (Rev. 11/6/2019) 2 00000 Xxxxx Xxxx • St. Louis, MO • 00000-0000 000-000-0000 Phone • 000-000-0000 Fax xxxx@xxxxxxxxxxxxxxxxx.xxx • xxx.xxxxxxxxxxxxxxxxx.xxx This is to acknowledge that I have received Care C are and Counseling’s Privacy Notice Name Signature Date 00000 Xxxxx Xxxx • St. Louis, MO • 00000-0000 000-000-0000 Phone • 000-000-0000 Fax xxxx@xxxxxxxxxxxxxxxxx.xxx • xxx.xxxxxxxxxxxxxxxxx.xxx Appointment Reminders APPOINTMENT REMINDERS Care and Counseling offers is now offering the option to for “Appointment Reminders.” You can receive an appointment reminder the day prior to your scheduled appointment by email (up to 2 email addresses) and/or by cell phone (only 1 phone number permitted). If you choose the reminder by phone, you have the option of via a text message message), your email address, or your phone (via a computer-computer generated voice message) the day before your scheduled appointment. Please select ONE of the following options: PHONE REMINDER (only one type of phone reminder can be provided): Text Message: I authorize Care and Counseling to send text message appointment reminders to me on my provided cell phone number. Text message charges from my cell phone provider may apply. Example of text message: “Do not reply-reminder-You have an appointment MON 01/11 at 4:00 PM – If you have any questions please call us at (000) 000-0000 – Name of Counselor Cell phone number to send text messages to: ( ) - Email message: I authorize Care and Counseling to send an email message appointment reminders to me on my provided email address. Example of email message from XxxxxxXxxxXxxxxxxx@xxxxxxxxXxxxxxx.xxx Hello, This is a reminder of your appointment on Monday – 01/11/2016 scheduled for 4:00 PM with Name of Counselor. If you have any questions regarding your appointment, please feel free to contact us at: (000) 000-0000. Thank you. Email address to send reminder messages to: Automated Voice Messages: I authorize Care and Counseling to send computer generated voice phone message appointment reminders to me on my provided phone number.