Common use of Your Choices Clause in Contracts

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: • Share information with your family, close friends, or others involved in your care • Share information in a disaster relief situation In these cases we never share your information unless you give us written permission: • Marketing purposes • Most sharing of psychotherapy notes • In the case of fundraising, we may contact you for fundraising efforts, but you can tell us not to contact you again. We typically use or share your health information in the following ways. • Treat you We can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition. • Run our organization We can use and share your health information to run our practice, improve your care, and contact you when necessary. Example: We use health information about you to manage your treatment and services. • Bill for your services We can use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for your services. We are allowed or required to share your information in other ways – usually in ways that 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. • Help with public health and safety issues We can share health information about you for certain situations such as: Preventing disease, reporting suspected abuse, neglect, or domestic violence, and 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. • 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, and 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. • We are required by law to maintain the privacy and security of your protected health information. We retain records for 7 years past closure, or 7 years past a minor youth turning 18. • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. • We must follow the duties and privacy practices described in this notice and give you a copy of it. • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. 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. xxxx@xxxxxxxxxxxxxxxxx.xxx • xxx.xxxxxxxxxxxxxxxxx.xxx Name Signature Date “Telehealth Services” encompasses Video Therapy and Telephone Counseling. Telehealth involves the delivery of psychotherapy counseling services using electronic communications, information technology or other means between a mental health clinician employed by or otherwise contracted with Care and Counseling, Inc. (“Provider”) and a client who are not in the same physical location. Telehealth Services may be used for diagnosis, treatment, follow-up and/or education. Please note that prior to beginning Telehealth Services, new clients will be screened by phone by their Provider to ensure suitability for this treatment modality. Care and Counseling is dedicated to ensuring you receive the best possible care with minimal interruptions. Many clients and Providers are moving to Telehealth services during a national crisis and to ensure health, safety, and continuity of care. For most clients, services will return to meeting in the same physical location (Care and Counseling office) when possible and agreed upon between the client and Provider. Please discuss the duration of Telehealth Services with your Provider. This guide is intended to help you successfully participate in Telehealth Services. It is not exhaustive and should not replace conversations with your Provider.

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: • Share information with your family, close friends, or others involved in your care • Share information in a disaster relief situation In these cases cases, we never share your information unless you give us written permission: • Marketing purposes • Most sharing Sale of psychotherapy notes • In the case of fundraising, we may contact you for fundraising efforts, but you can tell us not to contact you again. We typically use or share your health information in the following ways. • Treat you We can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition. • Run our organization We can use and share your health information to run our practice, improve your care, and contact you when necessary. Example: We use health information about you to manage your treatment and services. • Bill for your services We can use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for your services. We are allowed or required to share your information in other ways – usually in ways that contribute to coordinate your services with the public good, such as public health and researchcontracted or governing government agencies. We have are allowed or required to share some Participant Employer data, billing and accounts receivable information with our bank, government tax auditors, and CPA auditors. We must meet many conditions in the law before we can share your service information for these other purposes. For more information see: xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxxxxx/xxxxxxxxx/xxxxx.xxxxxxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxxxxx/xxxxxxxxx/xxxxx.xxxx . • Help with public We can use and share your health information to xxxx and safety issues get payment from health plans or other entities. We can share health information about you for certain situations such as: Preventing disease, reporting • Reporting suspected abuse, neglect, or domestic violence, and preventing 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 safety We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law. • Work with a medical examiner or funeral director We can share health information with a coroner, medical examiner, or funeral director when an individual dies. • Address workers’ compensation, law enforcement, and other government requests We can use or share health information about you for you: • For workers’ compensation claims, for claims • For law enforcement purposes or with a law enforcement official, with health official • With oversight agencies for activities authorized by law, and for special government functions such as military, national security, and presidential protective services • Respond to lawsuits and legal actions law We can share health service information about you in response to a covered request by the county, state or federal program requests. We can share service information about you in response to a court or administrative order, or in response to a subpoena. • We are required by law to maintain the privacy and security of your protected health information. We retain records for 7 years past closure, or 7 years past a minor youth turning 18. • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. • We must follow the duties and privacy practices described in this notice and give you a copy of it. • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. This notice is effective 11/6/2019For more information see: xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxxxxx/xxxxxxxxx/xxxxxxxx.xxxx . We can change the terms • Effective Date of this noticeNotice: 12/22/2020 • Privacy official: Xxxx Xxxxxxx, and CEO 000 Xxxx Xx. Xxxxxxx Xxxxxx, Xx. Xxxxx, Xxxxxxxxx 00000 xxxx@xxxxxxx.xxx (320) 420-1017 • We never market or sell personal information • We will never share any service records without your written permission; excluding government entities entitled to the changes will apply to all information • You can complain if you feel we have about youviolated your rights by contacting the privacy official listed above. The new notice • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 000 Xxxxxxxxxxxx Xxxxxx, X.X., Xxxxxxxxxx, X.X. 00000, calling 0-000-000-0000, or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. • We will be available upon requestnot retaliate against you for filing a complaint. Initial Here Self-Directed Services Participant Agreement THIS AGREEMENT is made effective on , in our officeby and between and , and on our web siteParticipant Employer or Managing Party. xxxx@xxxxxxxxxxxxxxxxx.xxx • xxx.xxxxxxxxxxxxxxxxx.xxx Name Signature Date “Telehealth Services” encompasses Video Therapy and Telephone Counseling. Telehealth involves the delivery of psychotherapy counseling services using electronic communications, information technology (Participant Employer or other means between a mental health clinician employed by or otherwise contracted with Care and Counseling, Inc. (“Provider”) and a client who are not in the same physical location. Telehealth Services may be used for diagnosis, treatment, follow-up and/or education. Please note that prior to beginning Telehealth Services, new clients will be screened by phone by their Provider to ensure suitability for this treatment modality. Care and Counseling is dedicated to ensuring you receive the best possible care with minimal interruptions. Many clients and Providers are moving to Telehealth services during a national crisis and to ensure health, safety, and continuity of care. For most clients, services will return to meeting in the same physical location (Care and Counseling office) when possible and agreed upon between the client and Provider. Please discuss the duration of Telehealth Services with your Provider. This guide is intended to help you successfully participate in Telehealth Services. It is not exhaustive and should not replace conversations with your Provider.Managing Party Name)

Your Choices. For certain health informationYou have some choices in the way that we use and share information as we: • Discuss your services with family, you can tell us your choices about what we share. If you have a clear preference for how we friends and caregivers • Provide disaster relief • Provide services • Market our services We may use and 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 toas we: • Share information with your family, close friends, or others involved in your care • Share information in a disaster relief situation In these cases we never share your information unless Serve you give us written permission: • Marketing purposes • Most sharing of psychotherapy notes • In the case of fundraising, we may contact you for fundraising efforts, but you can tell us not to contact you again. We typically use or share your health information in the following ways. • Treat you We can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition. • Run our organization We can use and share your health information to run our practice, improve your care, and contact you when necessary. Example: We use health information about you to manage your treatment and services. • Bill for your services We can use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for your services. We are allowed or required to share your information in other ways – usually in ways that 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. • Help with public health and safety issues We can share health information about you for certain situations such as: Preventing disease, reporting suspected abuse, neglect, or domestic violence, and 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 • Respond to required county, state or and federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law. • Work with a medical examiner or funeral director We can share health information with a coroner, medical examiner, or funeral director when an individual dies. program requests • 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, and for special government functions such as military, national security, and presidential protective services • Respond to lawsuits and legal actions We can share When it comes to your health information about information, you in response have certain rights. This section explains your rights and some of our responsibilities to a court or administrative order, or in response to a subpoenahelp you. • We are required by law You can ask to maintain the privacy and security see or get an electronic or paper copy of your protected medical record and other health information. We retain records for 7 years past closure, or 7 years past a minor youth turning 18. • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. • We must follow the duties and privacy practices described in this notice and give you a copy of it. • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. 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 Ask us how to do this. • We will be available upon provide a copy or a summary of your service information, usually within 30 days of your request. We may charge a reasonable, cost-based fee. • You can ask us to correct any information about you that you think is incorrect or incomplete. Ask us how to do this. • We may say “no” to your request, but we’ll tell you why in writing within 60 days. • 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. • We will say “yes” to all reasonable requests. • You can ask us not to use or share certain information for services, payment, or our officeoperations. We are not required to agree to your request, and on we may say “no” if it would affect your services or our web sitelegal obligation. xxxx@xxxxxxxxxxxxxxxxx.xxx • xxx.xxxxxxxxxxxxxxxxx.xxx Name Signature Date If you pay for a service or 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. We will say “Telehealth Servicesyes” encompasses Video Therapy and Telephone Counselingunless a law requires us to share that information. Telehealth involves • You can ask for a list (accounting) of the delivery of psychotherapy counseling services using electronic communications, times we’ve shared your service information technology or other means between a mental health clinician employed by or otherwise contracted with Care and Counseling, Inc. (“Provider”) and a client who are not in the same physical location. Telehealth Services may be used for diagnosis, treatment, follow-up and/or education. Please note that six years prior to beginning Telehealth Servicesthe date you ask, new clients who we shared it with, and why. • We will be screened by phone by their Provider include all the disclosures except for those about services, payment, and health care operations, and certain other disclosures (such as any you asked us to ensure suitability make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months. You can ask for a paper copy of this treatment modality. Care and Counseling is dedicated notice at any time, even if you have agreed to ensuring you receive the best possible care notice electronically. We will provide you with minimal interruptionsa paper copy promptly. Many clients • If you have given someone power of attorney or if someone is your legal guardian, that person can exercise your rights and Providers are moving to Telehealth services during a national crisis make choices about your service information. • We will make sure the person has this authority and to ensure health, safety, and continuity of care. For most clients, services will return to meeting in the same physical location (Care and Counseling office) when possible and agreed upon between the client and Provider. Please discuss the duration of Telehealth Services with your Provider. This guide is intended to help can act for you successfully participate in Telehealth Services. It is not exhaustive and should not replace conversations with your Providerbefore we take any action.

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: • Share information with your family, close friends, or others involved in your care • Share information in a disaster relief situation In these cases cases, we never share your information unless you give us written permission: • Marketing purposes • Most sharing Sale of psychotherapy notes • In your information We are allowed or required to share your information in other ways – usually in ways that coordinate your services with the case of fundraising, we may contact you for fundraising efforts, but you can tell us not to contact you againcontracted or governing government agencies. We typically use are allowed or required to share some Participant Employer data, billing and accounts receivable information with our bank, government tax auditors, and CPA auditors. We must meet many conditions in the law before we can share your health service information in the following waysfor other purposes. • Treat you We can use your health For more information and share it with other professionals who are treating yousee: xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxxxxx/xxxxxxxxx/xxxxx.xxxx . Example: A doctor treating you for an injury asks another doctor about your overall health condition. • Run our organization We can use and share your health information to run our practice, improve your care, and contact you when necessary. Example: We use health information about you to manage your treatment and services. • Bill for your services We can use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for your services. We are allowed or required to share your information in other ways – usually in ways that 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. • Help with public health and safety issues We can share health information about you for certain situations such as: Preventing disease, reporting • Reporting suspected abuse, neglect, or domestic violence, and preventing 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 safety We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law. • Work with a medical examiner or funeral director We can share health information with a coroner, medical examiner, or funeral director when an individual dies. • Address workers’ compensation, law enforcement, and other government requests We can use or share health information about you for you: • For workers’ compensation claims, for claims • For law enforcement purposes or with a law enforcement official, with health official • With oversight agencies for activities authorized by law, and for special government functions such as military, national security, and presidential protective services • Respond to lawsuits and legal actions law We can share health service information about you in response to a covered request by the county, state or federal program requests. We can share service information about you in response to a court or administrative order, or in response to a subpoena. • We are required by law to maintain the privacy and security of your protected health information. We retain records for 7 years past closure, or 7 years past a minor youth turning 18. • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. • We must follow the duties and privacy practices described in this notice and give you a copy of it. • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. This notice is effective 11/6/2019For more information see: xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxxxxx/xxxxxxxxx/xxxxxxxx.xxxx . We can change the terms • Effective Date of this noticeNotice: 12/22/2020 • Privacy official: Xxxx Xxxxxxx, and 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 written permission; excluding government entities entitled to the changes will apply to all information • You can complain if you feel we have about youviolated your rights by contacting the privacy official listed above. The new notice • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 000 Xxxxxxxxxxxx Xxxxxx, X.X., Xxxxxxxxxx, X.X. 00000, calling 0-000-000-0000, or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. • We will be available upon requestnot retaliate against you for filing a complaint. Initial Here Self-Directed Services Participant Agreement THIS AGREEMENT is made effective on , in our officeby and between and , and on our web siteParticipant Employer or Managing Party. xxxx@xxxxxxxxxxxxxxxxx.xxx • xxx.xxxxxxxxxxxxxxxxx.xxx Name Signature Date “Telehealth Services” encompasses Video Therapy and Telephone Counseling. Telehealth involves the delivery of psychotherapy counseling services using electronic communications, information technology (Participant Employer or other means between a mental health clinician employed by or otherwise contracted with Care and Counseling, Inc. (“Provider”) and a client who are not in the same physical location. Telehealth Services may be used for diagnosis, treatment, follow-up and/or education. Please note that prior to beginning Telehealth Services, new clients will be screened by phone by their Provider to ensure suitability for this treatment modality. Care and Counseling is dedicated to ensuring you receive the best possible care with minimal interruptions. Many clients and Providers are moving to Telehealth services during a national crisis and to ensure health, safety, and continuity of care. For most clients, services will return to meeting in the same physical location (Care and Counseling office) when possible and agreed upon between the client and Provider. Please discuss the duration of Telehealth Services with your Provider. This guide is intended to help you successfully participate in Telehealth Services. It is not exhaustive and should not replace conversations with your Provider.Managing Party Name)

Your Choices. For certain health information, you can tell us your You have some choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, way that we use and we will follow your instructions. In these cases, you have both the right and choice to tell us toshare information as we: • Share information Discuss your services with your family, close friends, or others involved in your care friends and caregivers • Share information in a Provide disaster relief situation In these cases we never share your information unless you give us written permission: • Marketing purposes Provide services • Most sharing of psychotherapy notes • In the case of fundraising, we Market our services We may contact you for fundraising efforts, but you can tell us not to contact you again. We typically use or share your health information in the following ways. • Treat you We can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition. • Run our organization We can use and share your health information to run as we: • Serve you • Run our practice, improve your care, and contact you when necessary. Example: We use health information about you to manage your treatment and services. organizagon • Bill Xxxx for your services We can use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for your services. We are allowed or required to share your information in other ways – usually in ways that 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. • Help with public health and safety issues We can share health information about you for certain situations such as: Preventing disease, reporting suspected abuse, neglect, or domestic violence, and 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 • Respond to required county, state or and federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law. • Work with a medical examiner or funeral director We can share health information with a coroner, medical examiner, or funeral director when an individual dies. program requests • Address workers’ compensationcompensagon, 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, and for special government functions such as military, national security, and presidential protective services • Respond to lawsuits and legal actions We can share acgons When it comes to your health information about information, you in response have certain rights. This section explains your rights and some of our responsibilities to a court or administrative order, or in response to a subpoenahelp you. • We are required by law You can ask to maintain the privacy and security see or get an electronic or paper copy of your protected medical record and other health information. We retain records for 7 years past closure, or 7 years past a minor youth turning 18. • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. • We must follow the duties and privacy practices described in this notice and give you a copy of it. • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. 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 Ask us how to do this. • We will be available upon provide a copy or a summary of your service information, usually within 30 days of your request. We may charge a reasonable, cost-based fee. • You can ask us to correct any information about you that you think is incorrect or incomplete. Ask us how to do this. • We may say “no” to your request, but we’ll tell you why in writing within 60 days. • 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. • We will say “yes” to all reasonable requests. • You can ask us not to use or share certain information for services, payment, or our officeoperations. We are not required to agree to your request, and on we may say “no” if it would affect your services or our web sitelegal obligation. xxxx@xxxxxxxxxxxxxxxxx.xxx • xxx.xxxxxxxxxxxxxxxxx.xxx Name Signature Date If you pay for a service or 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. We will say “Telehealth Servicesyes” encompasses Video Therapy and Telephone Counselingunless a law requires us to share that information. Telehealth involves • You can ask for a list (accounting) of the delivery of psychotherapy counseling services using electronic communications, times we’ve shared your service information technology or other means between a mental health clinician employed by or otherwise contracted with Care and Counseling, Inc. (“Provider”) and a client who are not in the same physical location. Telehealth Services may be used for diagnosis, treatment, follow-up and/or education. Please note that six years prior to beginning Telehealth Servicesthe date you ask, new clients who we shared it with, and why. • We will be screened by phone by their Provider include all the disclosures except for those about services, payment, and health care operations, and certain other disclosures (such as any you asked us to ensure suitability make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months. You can ask for a paper copy of this treatment modality. Care and Counseling is dedicated notice at any time, even if you have agreed to ensuring you receive the best possible care notice electronically. We will provide you with minimal interruptionsa paper copy promptly. Many clients • If you have given someone power of attorney or if someone is your legal guardian, that person can exercise your rights and Providers are moving to Telehealth services during a national crisis make choices about your service information. • We will make sure the person has this authority and to ensure health, safety, and continuity of care. For most clients, services will return to meeting in the same physical location (Care and Counseling office) when possible and agreed upon between the client and Provider. Please discuss the duration of Telehealth Services with your Provider. This guide is intended to help can act for you successfully participate in Telehealth Services. It is not exhaustive and should not replace conversations with your Providerbefore we take any action.

Your Choices. For certain health information, you can tell us me your choices about what we share. If you have a clear preference for how we I share your information in the situations described below, talk to usme. Tell us me what you want us to do, and we I will follow your instructions. In these cases, you have both the right and choice to tell us me to: • Share information with your family, close friends, or others involved in your care • Share information in a disaster relief situation • Include your information in a hospital directory If you are not able to tell me your preference, for example if you are unconscious, I may go ahead and share your information if I believe it is in your best interest. I may also share your information when needed to lessen a serious and imminent threat to health or safety. In these cases we I never share your information unless you give us me written permission: • Marketing purposes • Sale of your information • Most sharing of psychotherapy notes • In the case of fundraising, we : I may contact you for fundraising efforts, but you can tell us me not to contact you again. We How do I typically use or share your health information? I typically use or share your health information in the following ways. : • Treat you We I can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition. • Run our organization We I 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 I can use and share your health information to bill and get payment from health plans or other entities. Example: We I give information about you to your health insurance plan so it will pay for your services. We are How else can I use or share your health information? I am allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We I have to meet many conditions in the law before we I can share your information for these purposes. For more information see: xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxxxxx/xxxxxxxxx/xxxxx.xxxx. • Help with public health and safety issues We I can share health information about you for certain situations such as: • Preventing disease, reporting disease • Helping with product recalls • Reporting adverse reactions to medications • Reporting suspected abuse, neglect, or domestic violence, and preventing violence • Preventing or reducing a serious threat to anyone’s health or safety. safety • Do research We can use or share your information for health research. • Comply with the law We I will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re I’m complying with federal privacy law. • Work I can share health information about you with organ procurement organizations • I can work with a medical examiner or funeral director We • I can share health information with a coroner, medical examiner, or funeral director when an individual dies. dies • Address workers’ compensation, law enforcement, and other government requests We • I can use or share health information about you for workers’ compensation claims, for claims • For law enforcement purposes or with a law enforcement official, with official • With health oversight agencies for activities authorized by law, and for law • For special government functions such as military, national security, and presidential protective services • Respond to lawsuits and legal actions We • I can share health information about you in response to a court or administrative order, or in response to a subpoena. • We are I am required by law to maintain the privacy and security of your protected health information. We retain records for 7 years past closure, or 7 years past a minor youth turning 18. • We I will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. • We I must follow the duties and privacy practices described in this notice and give you a copy of it. • We I will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we me I can, you may change your mind at any time. Let us me know in writing if you change your mind. This notice is effective 11/6/2019For more information see: xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxxxxx/xxxxxxxxx/xxxxxxxx.xxxx. 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. xxxx@xxxxxxxxxxxxxxxxx.xxx • xxx.xxxxxxxxxxxxxxxxx.xxx Name Signature Date “Telehealth Services” encompasses Video Therapy and Telephone Counseling. Telehealth involves the delivery of psychotherapy counseling services using electronic communications, information technology not market or other means between a mental health clinician employed by or otherwise contracted with Care and Counseling, Inc. (“Provider”) and a client who are not in the same physical location. Telehealth Services may be used for diagnosis, treatment, follow-up and/or education. Please note that prior to beginning Telehealth Services, new clients will be screened by phone by their Provider to ensure suitability for this treatment modality. Care and Counseling is dedicated to ensuring you receive the best possible care with minimal interruptions. Many clients and Providers are moving to Telehealth services during a national crisis and to ensure health, safety, and continuity of care. For most clients, services will return to meeting in the same physical location (Care and Counseling office) when possible and agreed upon between the client and Provider. Please discuss the duration of Telehealth Services with your Provider. This guide is intended to help you successfully participate in Telehealth Services. It is not exhaustive and should not replace conversations with your Providersell personal information.

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: • Share information with your family, close friends, or others involved in your care • Share information in a disaster relief situation In these cases cases, we never share your information unless you give us written permission: • Marketing purposes • Most sharing Sale of psychotherapy notes • In your information We are allowed or required to share your information in other ways – usually in ways that coordinate your services with the case of fundraising, we may contact you for fundraising efforts, but you can tell us not to contact you againcontracted or governing government agencies. We typically use are allowed or required to share some Participant Employer data, billing and accounts receivable information with our bank, government tax auditors, and CPA auditors. We must meet many conditions in the law before we can share your health service information in the following waysfor other purposes. • Treat you We can use your health For more information and share it with other professionals who are treating yousee: xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxxxxx/ consumers/index.html. Example: A doctor treating you for an injury asks another doctor about your overall health condition. • Run our organization We can use and share your health information to run our practice, improve your care, and contact you when necessary. Example: We use health information about you to manage your treatment and services. • Bill for your services We can use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for your services. We are allowed or required to share your information in other ways – usually in ways that 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. • Help with public health and safety issues We can share health information about you for certain situations such as: Preventing disease, reporting • Reporting suspected abuse, neglect, or domestic violence, and preventing 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 safety We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law. • Work with a medical examiner or funeral director We can share health information with a coroner, medical examiner, or funeral director when an individual dies. • Address workers’ compensation, law enforcement, and other government requests We can use or share health information about you for you: • For workers’ compensation claims, for claims • For law enforcement purposes or with a law enforcement official, with health official • With oversight agencies for activities authorized by law, and for special government functions such as military, national security, and presidential protective services • Respond to lawsuits and legal actions law We can share health service information about you in response to a covered request by the county, state, or federal program requests. We can share service information about you in response to a court or administrative order, or in response to a subpoena. • We are required by law to maintain the privacy and security of your protected health information. We retain records for 7 years past closure, or 7 years past a minor youth turning 18. • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. • We must follow the duties and privacy practices described in this notice and give you a copy of it. • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. This notice is effective 11/6/2019For more information see: xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxxxxx/ consumers/noticepp.html. 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 sitewebsite. xxxx@xxxxxxxxxxxxxxxxx.xxx • xxx.xxxxxxxxxxxxxxxxx.xxx Name Signature Effective Date “Telehealth Services” encompasses Video Therapy of this Notice: 12/22/2020 • Privacy official: Xxxx Xxxxxxx, CEO 0000 Xxx Xx X, Xx. Xxxxxx, Minnesota 56374 (000) 000-0000 • We never market or sell personal information • We will never share any service records without your written permission; excluding government entities entitled to the information • 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 Telephone CounselingHuman 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/ privacy/hipaa/complaints/ • We will not retaliate against you for filing a complaint. Telehealth involves the delivery of psychotherapy counseling services using electronic communications, information technology or other means between a mental health clinician employed by or otherwise contracted with Care and Counseling, Inc. (“Provider”) and a client who are not in the same physical location. Telehealth Services may be used for diagnosis, treatment, follow-up and/or education. Please note that prior to beginning Telehealth Services, new clients will be screened by phone by their Provider to ensure suitability for this treatment modality. Care and Counseling is dedicated to ensuring you receive the best possible care with minimal interruptions. Many clients and Providers are moving to Telehealth services during a national crisis and to ensure health, safety, and continuity of care. For most clients, services will return to meeting in the same physical location (Care and Counseling office) when possible and agreed upon between the client and Provider. Please discuss the duration of Telehealth Services with your Provider. This guide is intended to help you successfully participate in Telehealth Services. It is not exhaustive and should not replace conversations with your Provider.Initial Here