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 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. 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 You can ask us to correct health 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.  Request confidential 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. We will say “yes” to all reasonable requests.  Ask us to limit what we use or share You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care. 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. We will say “yes” unless a law requires us to share that information.  Get a list of those with whom we’ve shared information You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.  Get a copy of this privacy notice You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.  Choose someone to act for you If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. 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 You can complain if you feel we have violated your rights by contacting 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 Services Office for Civil Rights by sending a letter to 000 Xxxxxxxxxxxx Xxxxxx, X.X., Xxxxxxxxxx, X.X. 00000, calling 1-877- 000-0000, or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. We will not retaliate against you for filing a complaint. 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.

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 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. 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- 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 (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. We may say “no” have 60 days to your request, but we’ll tell you why in writing within 60 dayscomply.  - Request confidential communications 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. o We will say “yes” do our best to meet all reasonable requests.  - Ask us to limit what the information we share or use or share o You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to meet your request, and we may say “no” deny your request if it would affect your care. 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. 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 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. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.  Get - Obtain a copy of this privacy notice 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 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. 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 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 our the Chief Clinical Director and Privacy Officer, Xxxxx Xxxxxx, LCSW at 314.336.1041. You can also call 000-000-0000 to reach our phone directory. o You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to via letter, telephone or online. § Address: 000 Xxxxxxxxxxxx Xxxxxx, X.X., Xxxxxxxxxx, X.X. 00000XX, calling 100000 § Phone Number: 0-877- 000-0000, or visiting 000-0000 § Website: xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. o We will not retaliate against you for exercising your rights and filing a complaint. 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.

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 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. 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 You can ask us to correct health 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.  • Request confidential 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. We will say “yes” to all reasonable requests.  • Ask us to limit what we use or share You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care. 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. We will say “yes” unless a law requires us to share that information.  • Get a list of those with whom we’ve shared information You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.  • Get a copy of this privacy notice You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.  • Choose someone to act for you If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. 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 You can complain if you feel we have violated your rights by contacting 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 Services Office for Civil Rights by sending a letter to 000 Xxxxxxxxxxxx Xxxxxx, X.X., Xxxxxxxxxx, X.X. 00000, calling 1-877- 000-0000, or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. We will not retaliate against you for filing a complaint. 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 Notice of Privacy Practices (Rev. 11/6/2019) 1 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.

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 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 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 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 • 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. • 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- cost-based fee.  Ask us to correct your medical record • You can ask us to correct health 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.  Request confidential 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. • We will say “yes” to all reasonable requests.  Ask us to limit what we use or share • You can ask us not to use or share certain health information for treatmentservices, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your careservices or our legal obligation. • 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. We will say “yes” unless a law requires us to share that information.  Get a list of those with whom we’ve shared information • You can ask for a list (accounting) of the times we’ve shared your health service information for six years prior to the date you ask, who we shared it with, and why. • 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 12 months.  Get a copy of this privacy notice You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.  Choose someone to act for you • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health service information. • 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 You can complain if you feel we have violated your rights by contacting 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 Services Office for Civil Rights by sending a letter to 000 Xxxxxxxxxxxx Xxxxxx, X.X., Xxxxxxxxxx, X.X. 00000, calling 1-877- 000-0000, or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. We will not retaliate against you for filing a complaint. 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.

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 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. 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 You can ask us to correct health 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.  • Request confidential 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. We will say “yes” to all reasonable requests.  • Ask us to limit what we use or share You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care. 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. We will say “yes” unless a law requires us to share that information.  • Get a list of those with whom we’ve shared information You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.  • Get a copy of this privacy notice You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.  • Choose someone to act for you If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. 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 You can complain if you feel we have violated your rights by contacting 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 Services Office for Civil Rights by sending a letter to 000 Xxxxxxxxxxxx Xxxxxx, X.X., Xxxxxxxxxx, X.X. 00000, calling 10-877- 000-000-0000, or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. Notice of Privacy Practices (Rev. 11/6/2019) 1 We will not retaliate against you for filing a complaint. 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.

Your Rights. When it comes Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights. You have the right to request a restriction of your protected 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 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. We will provide a copy or a summary of your health information, usually within 30 days of your request. We means you may charge a reasonable, cost- based fee.  Ask us to correct your medical record You can ask us to correct health 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.  Request confidential 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. We will say “yes” to all reasonable requests.  Ask us to limit what we use or share You can ask us not to use or share certain disclose any part of your protected health information for the purposes of treatment, payment, payment or our healthcare operations. We are You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice. Citizens is not required to agree to a restriction that you may request. If Citizens believes it is in your best interest to permit use and disclosure of your protected health information, or that it is not reasonably feasible to comply with your request, your protected health information will not be restricted. If Citizens does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment as part of provision of your services. You may request a restriction by submitting a written request to Citizens. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests that are feasible to implement. We may also condition the accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. You make this request in writing to Citizens. You may have the right to have Citizens amend your protected health information. This means you may request an amendment of protected health information about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may say “no” if it would affect prepare a rebuttal to your care. If statement and will provide 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. We will say “yes” unless a law requires us to share that information.  Get a list of those with whom we’ve shared information You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.  Get a copy of any such rebuttal. You may request an amendment by submitting a written request to Citizens. You have the right to receive an accounting of certain disclosures we have made, if any, of your personal and protected health information. This right applies to disclosures for purposes other than provision of PERS services, treatment, payment or healthcare operations as described in this privacy notice Notice of Privacy Practices. It excludes disclosures we may have made to you, to family members or friends involved in your care, or for notification purposes. You can ask for have the right to receive specific information regarding these disclosures that occurred after August 1, 2012. The right to receive this information is subject to certain exceptions, restrictions and limitations. To request an accounting of disclosures, you may contact Citizens. You have the right to obtain a paper copy of this notice at any timeNotice from us, upon request, even if you have agreed to receive the notice accept this Notice electronically. We will provide you with a paper copy promptly.  Choose someone to act for you If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. 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 You can complain if you feel we have violated your rights by contacting 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 Services Office for Civil Rights by sending a letter to 000 Xxxxxxxxxxxx Xxxxxx, X.X., Xxxxxxxxxx, X.X. 00000, calling 1-877- 000-0000, or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. We will not retaliate against you for filing a complaint. 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.

Your Rights. When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities those rights. Ask to help you.  Get an electronic or paper see a copy of your medical record 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 either you or the representative may bring one person of your choosing. • 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. • 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- cost-based feefee of $0.25 per page.  Ask us • 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 correct 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 record 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. • 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. 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 • 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” agree to all reasonable requests.  Ask us to limit what we use or share • You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would could affect your care. • 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. We will say “yes” unless a law requires us to share that information.  Get a list of those with whom we’ve shared 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. • 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 12 months.  Get a copy of this privacy notice You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.  Choose someone to act for you • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. • 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 You can complain • Please let us know if you feel we have violated your rights by contacting not upheld our Clinical Director and Privacy Officer, Xxxxx Xxxxxx, LCSW at 314.336.1041obligations. Contact us using the information on page 1 of this Notice. • You can also 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 10-877- 000-000-0000, or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. • We will not retaliate against you for filing a complaint. 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.

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 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. 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- 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 (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. We may say “no” have 60 days to your request, but we’ll tell you why in writing within 60 dayscomply.  - Request confidential communications 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. o We will say “yes” do our best to meet all reasonable requests.  - Ask us to limit what the information we share or use or share o You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to meet your request, and we may say “no” deny your request if it would affect your care. 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. 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 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. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.  Get - Obtain a copy of this privacy notice 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 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. 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 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 our the Chief Clinical Director and Privacy Officer, Xxxxx Xxxxxx, LCSW at 314.336.1041. You can also call 000-000-0000 to reach our phone directory. o You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to via letter, telephone or online. ▪ Address: 000 Xxxxxxxxxxxx Xxxxxx, X.X., Xxxxxxxxxx, X.X. 00000XX, calling 100000 ▪ Phone Number: 0-877- 000-0000, or visiting 000-0000 ▪ Website: xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. o We will not retaliate against you for exercising your rights and filing a complaint. 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.

Your Rights. When it comes to your health information, you You have certain rights. This section explains your rights and some of our responsibilities to help you.  the right to: • Get an electronic or paper 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 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 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 • 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. • 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 • You can ask us to correct health 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.  Request confidential 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. • We will say “yes” to all reasonable requests.  Ask us to limit what we use or share • You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care. • 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. We will say “yes” unless a law requires us to share that information.  Get a list of those with whom we’ve shared information • You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. • We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.  Get a copy of this privacy notice You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.  Choose someone to act for you • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. • 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 • You can complain if you feel we have violated your rights by contacting our Clinical Director and Privacy Officer, Xxxxx Xxxxxx, LCSW at 314.336.1041us using the information on page 1. • You can also 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 10-877- 000-000-0000, or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. • We will not retaliate against you for filing a complaint. 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 • Include your information in a hospital directory In these cases we never share your information unless you give us written permission:  • Marketing purposes  • Sale of your information • Most sharing of psychotherapy notes  In the case of fundraising, we : • 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. 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 * 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. * 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- cost-based fee.  Ask us to correct your medical record 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 this. this by using the contact * We may say “no” to your request, but we. We’ll tell you why in writing within 60 days.  Request confidential 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. communications address Ask us how to do this by using the contact information at the end * 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.  Ask us to limit what we use or share You can ask us not to use or share certain health information for treatment, payment, payment or our operations. 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. 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. We will say “yes” unless a law requires us to share that information.  Get a list of those with whom we’ve shared information You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. * 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 provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.  Get a copy of this privacy notice * You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.  Choose someone to act for you * If you have given someone medical power of attorney or if someone is your legal for you guardian, that person can exercise your rights and make choices about your health information. 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 * You can complain if you feel we have violated your privacy rights by contacting our Clinical Director and Privacy Officer, Xxxxx Xxxxxx, LCSW using the you feel your rights contact information at 314.336.1041the end of this notice. You can also 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 1-877- 000-0000, or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. * We will not retaliate against you for filing a complaint. 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.

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 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. 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 You can ask us to correct health 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.  Request confidential 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. We will say “yes” to all reasonable requests.  Ask us to limit what we use or share You can ask us not to use or share certain health information for treatment, payment, or our operations. We are sending you a third notice because we did not required to agree to receive the pre-addressed response card or other written notice from you indicating your request, and we may say “no” if it would affect your carerejection of the proposed transfer. If you pay for a service or health care item out-of-pocket in fullwant your policy transferred to Zenith Insurance Company, you can ask may notify us not in writing by signing and returning the enclosed pre-addressed, postage-paid card or by writing to share that information us at: RISCORP National Insurance Company Xxx Xxxxxxxx Xxxxx Xxxxx 000 Xxxxxxxx, XX 00000 000-000-0000 IF YOU DO NOT WANT YOUR POLICY TRANSFERRED, YOU MUST NOTIFY US IN WRITING BY SIGNING AND RETURNING THE ENCLOSED PRE-ADDRESSED, POSTAGE-PAID CARD OR BY WRITING TO US AT THE ABOVE ADDRESS. IF WE DO NOT RECEIVE YOUR WRITTEN REJECTION WITHIN THIRTY DAYS OF THE DATE OF THIS THIRD AND FINAL NOTICE, YOU WILL BE DEEMED TO HAVE ACCEPTED THE TRANSFER. If you reject the transfer, you may keep your policy with RISCORP National Insurance Company or exercise any option under your policy. EFFECT OF TRANSFER If you accept this transfer, Zenith Insurance Company will be your insurer. It will have direct responsibility to you for the purpose payment of payment or our operations with your health insurerall claims, benefits and for all other policy obligations. We RISCORP National Insurance Company will say “yes” unless a law requires us no longer have any obligations to share that informationyou.  Get a list of those with whom we’ve shared information You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.  Get a copy of this privacy notice You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.  Choose someone to act for you If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has accept this authority and can act for you before we take any action.  File a complaint if you feel your rights are violated You can complain if you feel we have violated your rights by contacting 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 Services Office for Civil Rights by sending a letter to 000 Xxxxxxxxxxxx Xxxxxx, X.X., Xxxxxxxxxx, X.X. 00000, calling 1-877- 000-0000, or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. We will not retaliate against you for filing a complaint. Your Choices For certain health informationtransfer, you can tell us should make all premium payments and claims submissions to Zenith Insurance Company and direct all questions to Zenith Insurance Company. -5- For your choices about what we shareconvenience, a pre-addressed postage-paid response card is enclosed. Please take time now to read the enclosed notice and complete and return the response card. If you have a clear preference any further questions about this agreement, you may contact RISCORP National Insurance Company or Zenith Insurance Company. Sincerely, ___________________ _____________________ RISCORP NATIONAL INSURANCE COMPANY ZENITH INSURANCE COMPANY One Sarasota Tower 0000 Xxxx Xxxxxx Xxxxx 000 Xxxxxxxx, XX 00000 Xxxxxxxx, XX 00000 -6- ----------------------------------------------------------------- RESPONSE CARD _________ YES, I accept the transfer of my policy from RISCORP National Insurance Company to Zenith Insurance Company. _________ NO, I reject the proposed transfer of my policy from RISCORP National Insurance Company to Zenith Insurance Company and wish to retain my policy with RISCORP National Insurance Company. _____________ ______________________________ DATE SIGNATURE NAME: _______________________________________________________________________ STREET ADDRESS: _______________________________________________________________________ CITY, STATE, ZIP: _______________________________________________________________________ -7- GEORGIA EXHIBIT A RISCORP NATIONAL INSURANCE COMPANY ZENITH INSURANCE COMPANY ONE SARASOTA TOWER 0000 XXXX XXXXXX XXXXX 000 XXXXXXXX, XX 00000 XXXXXXXX, XXXXXXX 00000 NOTICE OF TRANSFER AND CERTIFICATE OF ASSUMPTION IMPORTANT: THIS NOTICE AFFECTS YOUR CONTRACT RIGHTS. PLEASE READ IT CAREFULLY. TRANSFER OF POLICY Zenith Insurance Company has agreed to replace RISCORP National Insurance Company as your insurer under [insert policy/certificate name and number] effective [insert date]. Zenith Insurance Company's principal place of business is 00000 Xxxxxx Xxxxxx, Xxxxxxxx Xxxxx, Xxxxxxxxxx, 00000-0000; however, all correspondence with Zenith Insurance Company concerning your policy should be sent to 0000 Xxxx Xxxxxx, Xxxxxxxx, Xxxxxxx 00000. Attached to this notice is an explanation of the reason for how we share your information the transfer. Zenith Insurance Company is licensed in the situations described belowfollowing states: Alabama, talk Arizona, Arkansas, California, Colorado, Connecticut, Delaware, the District of Columbia, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Nebraska, New Jersey, New Mexico, New York, North Carolina, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia and Wisconsin. If Zenith Insurance Company is not licensed in the state where you reside, this transfer may affect your guarantee fund protection or your Insurance Commissioner's ability to usassist you with any matters concerning the company. Tell us what YOUR RIGHTS You may choose to consent to or reject the transfer of your policy to Zenith Insurance Company. If you want us to do, and we will follow your instructions. In these casespolicy transferred, you have both may notify us in writing by signing and returning the right and choice enclosed pre-addressed, postage-paid card or by writing to tell us toat:  Share RISCORP National Insurance Company Xxx Xxxxxxxx Xxxxx Xxxxx 000 Xxxxxxxx, Xxxxxxx 00000 000-000-0000 You may obtain additional information with your family, close friends, or others involved concerning Zenith from reference materials in your care  Share information in a disaster relief situation In these cases we never share local library or by contacting Xxxx X. Xxxxxxxx, Insurance and Safety Fire Commissioner, Regulatory Services Division, Georgia Department of Insurance, Suite 604, West Tower, Xxxxx Building, 0 Xxxxxx Xxxxxx Xxxx, Xx. Drive, Atlanta, Georgia 30334 (tel. (000) 000-0000). IF YOU DO NOT WANT YOUR POLICY TRANSFERRED, YOU MUST NOTIFY US IN WRITING BY SIGNING AND RETURNING THE ENCLOSED PRE-ADDRESSED, POSTAGE-PAID CARD OR BY WRITING TO US AT THE ABOVE ADDRESS. IF WE DO NOT RECEIVE YOUR WRITTEN REJECTION WITHIN THIRTY, YOU WILL BE SENT A SECOND NOTICE. IF WE DO NOT RECEIVE YOUR WRITEN REJECTION WITHIN THIRTY DAYS AFTER THE DATE OF THE SECOND NOTICE YOU WILL BE SENT A THIRD NOTICE. IF WE DO NOT RECEIVE YOUR WRITTEN REJECTION WITHIN THIRTY DAYS AFTER THE DATE OF THE THIRD NOTICE, YOU WILL BE DEEMED TO HAVE ACCEPTED THE TRANSFER. If you reject the transfer, you may keep 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 againpolicy with RISCORP Insurance Company or exercise any option under your policy.

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 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. 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 You can ask us to correct health 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.  Request confidential 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. We will say “yes” to all reasonable requests.  Ask us to limit what we use or share You can ask us not to use or share certain health information for treatment, payment, or our operations. We are sending you a second notice because we did not required to agree to receive the pre-addressed response card or other written notice from you indicating your request, and we may say “no” if it would affect your carerejection of the proposed transfer. If you pay for a service or health care item out-of-pocket in fullwant your policy transferred to Zenith Insurance Company, you can ask may notify us not in writing by signing and returning the enclosed pre-addressed, postage-paid card or by writing to share that information us at: RISCORP Property & Casualty Insurance Company Xxx Xxxxxxxx Xxxxx Xxxxx 000 Xxxxxxxx, XX 00000 000-000-0000 IF YOU DO NOT WANT YOUR POLICY TRANSFERRED, YOU MUST NOTIFY US IN WRITING BY SIGNING AND RETURNING THE ENCLOSED PRE-ADDRESSED, POSTAGE-PAID CARD OR BY WRITING TO US AT THE ABOVE ADDRESS. IF WE DO NOT RECEIVE YOUR WRITTEN REJECTION WITHIN THIRTY DAYS, YOU WILL BE SENT A THIRD NOTICE. IF WE DO NOT RECEIVE YOUR WRITTEN REJECTION WITHIN THIRTY (30) DAYS AFTER THE DATE OF THE THIRD NOTICE, YOU WILL BE DEEMED TO HAVE ACCEPTED THE TRANSFER. If you reject the transfer, you may keep your policy with RISCORP Property & Casualty Insurance Company or exercise any option under your policy. EFFECT OF TRANSFER If you accept this transfer, Zenith Insurance Company will be your insurer. It will have direct responsibility to you for the purpose payment of payment or our operations with your health insurerall claims, benefits and for all other policy obligations. We RISCORP Property & Casualty Insurance Company will say “yes” unless a law requires us no longer have any obligations to share that informationyou.  Get a list of those with whom we’ve shared information You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.  Get a copy of this privacy notice You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.  Choose someone to act for you If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has accept this authority and can act for you before we take any action.  File a complaint if you feel your rights are violated You can complain if you feel we have violated your rights by contacting 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 Services Office for Civil Rights by sending a letter to 000 Xxxxxxxxxxxx Xxxxxx, X.X., Xxxxxxxxxx, X.X. 00000, calling 1-877- 000-0000, or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. We will not retaliate against you for filing a complaint. Your Choices For certain health informationtransfer, you can tell us your choices about what we shareshould make all premium payments and claims submissions to Zenith Insurance Company and direct all questions to Zenith Insurance Company. 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 casesany further questions about this agreement, you have both may contact RISCORP Property & Casualty Insurance Company or Zenith Insurance Company. For your convenience, a pre-addressed postage-paid response card is enclosed. Please take time now to read the right enclosed notice and choice complete and return the response card. Sincerely, ___________________________ ________________________ RISCORP PROPERTY & CASUALTY ZENITH INSURANCE COMPANY INSURANCE COMPANY 0000 Xxxx Xxxxxx One Sarasota Tower Sarasota, FL 34236 Xxxxx 000 Xxxxxxxx, XX 00000 RISCORP PROPERTY & CASUALTY ZENITH INSURANCE COMPANY INSURANCE COMPANY 0000 XXXX XXXXXX ONE SARASOTA TOWER SARASOTA, FL 34236 SUITE 608 XXXXXXXX, XX 00000 THIRD AND FINAL NOTICE NOTICE OF TRANSFER AND CERTIFICATE OF ASSUMPTION IMPORTANT: THIS NOTICE AFFECTS YOUR CONTRACT RIGHTS. PLEASE READ IT CAREFULLY. TRANSFER OF POLICY You were previously sent a Notice of Transfer and Certificate of Assumption notifying you that Zenith Insurance Company has agreed to tell us to:  Share replace RISCORP Property & Casualty Insurance Company as your insurer under [insert policy/certificate name and number] effective [insert date]. Zenith Insurance Company's principal place of business is 00000 Xxxxxx Xxxxxx, Xxxxxxxx Xxxxx, Xxxxxxxxxx, 00000-0000; however, all correspondence with Zenith Insurance Company concerning your policy should be sent to 0000 Xxxx Xxxxxx, Xxxxxxxx, Xxxxxxx 00000. You may obtain additional information with your family, close friends, or others involved concerning Zenith Insurance Company from reference materials in your care  Share information in a disaster relief situation In these cases we never share local library or by contacting 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 againInsurance Commissioner at [insert address and phone number].

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 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 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 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 • 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. • 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- cost-based fee.  Ask us to correct your medical record • You can ask us to correct health 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.  Request confidential 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. • We will say “yes” to all reasonable requests.  Ask us to limit what we use or share • You can ask us not to use or share certain health information for treatmentservices, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your careservices or our legal obligation. • 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. We will say “yes” unless a law requires us to share that information.  Get a list of those with whom we’ve shared information • You can ask for a list (accounting) of the times we’ve shared your health service information for six years prior to the date you ask, who we shared it with, and why. • 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-cost- based fee if you ask for another one within 12 months.  Get a copy of this privacy notice You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.  Choose someone to act for you • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health service information. • 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 You can complain if you feel we have violated your rights by contacting 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 Services Office for Civil Rights by sending a letter to 000 Xxxxxxxxxxxx Xxxxxx, X.X., Xxxxxxxxxx, X.X. 00000, calling 1-877- 000-0000, or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. We will not retaliate against you for filing a complaint. 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.

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 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. 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 You can ask us to correct health 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.  Request confidential 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. We will say “yes” to all reasonable requests.  Ask us to limit what we use or share You can ask us not to use or share certain health information for treatment, payment, or our operations. We are sending you a second notice because we did not required to agree to receive the pre-addressed response card or other written notice from you indicating your request, and we may say “no” if it would affect your carerejection of the proposed transfer. If you pay for a service or health care item out-of-pocket in fullwant your policy transferred to Zenith Insurance Company, you can ask may notify us not in writing by signing and returning the enclosed pre-addressed, postage-paid card or by writing to share that information us at: RISCORP National Insurance Company Xxx Xxxxxxxx Xxxxx Xxxxx 000 Xxxxxxxx, XX 00000 000-000-0000 IF YOU DO NOT WANT YOUR POLICY TRANSFERRED, YOU MUST NOTIFY US IN WRITING BY SIGNING AND RETURNING THE ENCLOSED PRE-ADDRESSED, POSTAGE-PAID CARD OR BY WRITING TO US AT THE ABOVE ADDRESS. IF WE DO NOT RECEIVE YOUR WRITTEN REJECTION WITHIN THIRTY DAYS, YOU WILL BE SENT A THIRD NOTICE. IF WE DO NOT RECEIVE YOUR WRITTEN REJECTION WITHIN THIRTY (30) DAYS AFTER THE DATE OF THE THIRD NOTICE, YOU WILL BE DEEMED TO HAVE ACCEPTED THE TRANSFER. If you reject the transfer, you may keep your policy with RISCORP National Insurance Company or exercise any option under your policy. EFFECT OF TRANSFER If you accept this transfer, Zenith Insurance Company will be your insurer. It will have direct responsibility to you for the purpose payment of payment or our operations with your health insurerall claims, benefits and for all other policy obligations. We RISCORP National Insurance Company will say “yes” unless a law requires us no longer have any obligations to share that informationyou.  Get a list of those with whom we’ve shared information You can ask for a list (accounting) of the times we’ve shared your health information for six years prior If you accept this transfer, you should make all premium payments and claims submissions to the date you ask, who we shared it with, Zenith Insurance Company and whydirect all questions to Zenith Insurance Company. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.  Get a copy of this privacy notice You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.  Choose someone to act for you -3- If you have given someone medical power any further questions about this agreement, you may contact RISCORP National Insurance Company or Zenith Insurance Company. For your convenience, a pre-addressed postage-paid response card is enclosed. Please take time now to read the enclosed notice and complete and return the response card. Sincerely, ___________________ _____________________ RISCORP NATIONAL INSURANCE COMPANY ZENITH INSURANCE COMPANY One Sarasota Tower 0000 Xxxx Xxxxxx Xxxxx 000 Xxxxxxxx, XX 00000 Xxxxxxxx, XX 00000 -4- RISCORP NATIONAL INSURANCE COMPANY ZENITH INSURANCE COMPANY ONE SARASOTA TOWER 0000 XXXX XXXXXX XXXXX 000 XXXXXXXX, XX 00000 XXXXXXXX, XX 00000 THIRD AND FINAL NOTICE NOTICE OF TRANSFER AND CERTIFICATE OF ASSUMPTION IMPORTANT: THIS NOTICE AFFECTS YOUR CONTRACT RIGHTS. PLEASE READ IT CAREFULLY. TRANSFER OF POLICY You were previously sent a Notice of attorney or if someone Transfer and Certificate of Assumption notifying you that Zenith Insurance Company has agreed to replace RISCORP National Insurance Company as your insurer under [insert policy/certificate name and number] effective [insert date]. Zenith Insurance Company's principal place of business is your legal guardian, that person can exercise your rights and make choices about your health information. 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 You can complain if you feel we have violated your rights by contacting our Clinical Director and Privacy Officer, Xxxxx 00000 Xxxxxx Xxxxxx, LCSW at 314.336.1041. You can also 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.Xxxxxxxx Xxxxx, Xxxxxxxxxx, X.X. 00000, calling 1-877- 000-0000; however, or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. We will not retaliate against you for filing a complaintall correspondence with Zenith Insurance Company concerning your policy should be sent to 0000 Xxxx Xxxxxx, Xxxxxxxx, Xxxxxxx 00000. 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 You may obtain additional 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 concerning Zenith Insurance Company from reference materials in your care  Share information in a disaster relief situation In these cases we never share local library or by contacting 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 againInsurance Commissioner at [insert address and phone number].

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 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 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 - 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. - 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 - You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. - We may say “no” to deny your request, but we’ll we will tell you why in writing within 60 days.  Request confidential 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. - We will say “yes” agree to all reasonable requests.  Ask us to limit what we use or share - You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” deny your request if it would affect your care. - 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. 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 - 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. - 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 12 months.  Get a copy of this privacy notice - You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.  Choose someone to act for you - If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. - 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 - You can complain if you feel we have violated your rights by contacting our Clinical Director and Privacy Officer, Xxxxx Xxxxxx, LCSW at 314.336.1041. You can also file a complaint with us using 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 1-877- 000-0000, or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. We will not retaliate against you for filing a complaint. 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 instructionson Page . In these cases, you have both the right and choice to tell us to:  - Share information with your family, close friends, or others involved in your care  - Share information in a disaster relief situation If you are not able to tell us our preference, for example if you are unconscious, we may 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 permissionpermission to so. Such may include marketing purposes or testimonials. We typically use or share your health information in the following ways and you hereby consent to such use. - We can use your health information and share with other professionals who are treating you. - Example:  Marketing purposes  Most sharing of psychotherapy notes  In the case of fundraisingA doctor treating you for an injury asks another doctor about your overall health condition. - We can use and share your health information to run our business, we may improve your care, and contact you when necessary. - Example: We use health information about you to management your treatment and 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 fundraising effortsyour services. - We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, but 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. - 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 - We can tell us not use or share your information for health research - 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 contact you againsee that we’re complying with federal privacy law. - 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. I hereby consent to be photographed while receiving care and authorize Brain Builder Pros 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 Brain Builder Pros. 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 Brain Builder Pros 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. I authorize Brain Builder Pros to receive a copy of any Living Will, Durable Power of Attorney/Health Care Proxy, Advance Directive for Healthcare, and/or any other such document that I have executed. The documents are located at or with I certify that I have been instructed about, received a copy of and understand the patient/client Rights on Advance Directives which was explained to me orally by a representative of Brain Builder Pros. Reviewed/Revised: Patient/Client Name: I hereby authorize Redline Exercise Rx to render appropriate services to the patient/client named above. I understand an appropriate level of staff will provide such care. I recognize and agree that I have the right to refuse treatment or terminate services at any time by notifying the Redline Exercise Rx office in writing. In addition Redline Exercise Rx may terminate services by notifying me of termination.

Your Rights. When it comes to your health information, you You have certain rights. This section explains your rights and some of our responsibilities to help you.  the right to: • Get an electronic or paper 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 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 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 • 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. • 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 • You can ask us to correct health 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.  Request confidential 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. • We will say “yes” to all reasonable requests.  Ask us to limit what we use or share • You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care. • 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. We will say “yes” unless a law requires us to share that information.  Get a list of those with whom we’ve shared information • You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. • We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.  Get a copy of this privacy notice You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.  Choose someone to act for you • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. • 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 • You can complain if you feel we have violated your rights by contacting our Clinical Director and Privacy Officer, Xxxxx Xxxxxx, LCSW at 314.336.1041us using the information provided. • You can also 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 10-877- 000-000-0000, or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. • We will not retaliate against you for filing a complaint. 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 • Include your information unless you give us written permission:  in a hospital directory • Marketing purposes  • Sale of your information • Most sharing of psychotherapy notes  In the case of fundraising, we : • 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. 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 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 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 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 • 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. • 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- cost-based fee.  Ask us to correct your medical record • You can ask us to correct health 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.  Request confidential 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. • We will say “yes” to all reasonable requests.  Ask us to limit what we use or share • You can ask us not to use or share certain health information for treatmentservices, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your careservices or our legal obligation. • 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. We will say “yes” unless a law requires us to share that information.  Get a list of those with whom we’ve shared information • You can ask for a list (accounting) of the times we’ve shared your health service information for six years prior to the date you ask, who we shared it with, and why. • 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 12 months.  Get a copy of this privacy notice You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.  Choose someone to act for you • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health service information. • 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 You can complain if you feel we have violated your rights by contacting 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 Services Office for Civil Rights by sending a letter to 000 Xxxxxxxxxxxx Xxxxxx, X.X., Xxxxxxxxxx, X.X. 00000, calling 1-877- 000-0000, or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. We will not retaliate against you for filing a complaint. 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.

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 ● 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. ● 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 ● You can ask us to correct health 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.  Request confidential 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. ● We will say “yes” to all reasonable requests.  Ask us to limit what we use or share ● You can ask us not to use or share certain health information for treatment, payment, or our operations. ○ We are not required to agree to your request, and we may say “no” if it would affect your care. ● 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. ○ We will say “yes” unless a law requires us to share that information.  Get a list of those with whom we’ve shared information ● You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. ● We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.  Get a copy of this privacy notice ● You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.  Choose someone to act for you ● If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. ● 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 ● You can complain if you feel we have violated your rights by contacting our Clinical Director and Privacy Officer, Xxxxx Xxxxxx, LCSW at 314.336.1041us using the information on page 1. ● You can also file a complaint with the U.S. Department of Health and Human Services Office Offi e for Civil Rights by sending a letter to 000 Xxxxxxxxxxxx Xxxxxx, X.X., Xxxxxxxxxx, X.X. 00000, calling 10-877- 000-000-0000, or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. ● 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. 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 ● Include your information in a hospital directory ● Contact you for fundraising efforts In these cases we never share your information unless you give us written permission:  ● Marketing purposes  ● Sale of your information ● Most sharing of psychotherapy notes  In the case of fundraising, we : ● We may contact you for fundraising efforts, but you can tell us not to contact you again. ● How do we typically use or share your health information? 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.

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 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 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 - 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. - 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 - You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. - We may say “no” to deny your request, but we’ll we will tell you why in writing within 60 days.  Request confidential 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. - We will say “yes” agree to all reasonable requests.  Ask us to limit what we use or share - You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” deny your request if it would affect your care. - 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. 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 - 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. - 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 12 months.  Get a copy of this privacy notice - You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.  Choose someone to act for you - If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. - 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 - You can complain if you feel we have violated your rights by contacting our Clinical Director and Privacy Officer, Xxxxx Xxxxxx, LCSW at 314.336.1041. You can also file a complaint with us using 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 1-877- 000-0000, or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. We will not retaliate against you for filing a complaint. 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 instructionson Page . In these cases, you have both the right and choice to tell us to:  - Share information with your family, close friends, or others involved in your care  - Share information in a disaster relief situation If you are not able to tell us our preference, for example if you are unconscious, we may 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 permissionpermission to so. Such may include marketing purposes or testimonials. We typically use or share your health information in the following ways and you hereby consent to such use. - We can use your health information and share with other professionals who are treating you. - Example:  Marketing purposes  Most sharing of psychotherapy notes  In the case of fundraisingA doctor treating you for an injury asks another doctor about your overall health condition. - We can use and share your health information to run our business, we may improve your care, and contact you when necessary. - Example: We use health information about you to management your treatment and 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 fundraising effortsyour services. - We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, but 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. - 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 - We can tell us not use or share your information for health research - 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 contact you againsee that we’re complying with federal privacy law. - 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. 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. 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 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 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. 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- cost-based fee.  Ask us to correct your medical service record You can ask us to correct health 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.  Request confidential 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. We will say “yes” to all reasonable requests.  Ask us to limit what we use or share You can ask us not to use or share certain health information for treatmentservices, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your careservices or our legal obligation. 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. We will say “yes” unless a law requires us to share that information.  Get a list of those with whom we’ve shared information You can ask for a list (accounting) of the times we’ve shared your health service information for six years prior to the date you ask, who we shared it with, and why. 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 12 months.  Get a copy of this privacy notice You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.  Choose someone to act for you If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health service information. 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 You can complain if you feel we have violated your rights by contacting 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 Services Office for Civil Rights by sending a letter to 000 Xxxxxxxxxxxx Xxxxxx, X.X., Xxxxxxxxxx, X.X. 00000, calling 1-877- 000-0000, or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. We will not retaliate against you for filing a complaint. 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 Our Uses and Disclosures Serve you We are allowed or required to share your information in other ways – usually in ways that coordinate your services with the case of fundraisingcontracted 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 may contact 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 fundraising effortscertain situations such as: Reporting suspected abuse, but neglect, or domestic violence Preventing or reducing a serious threat to anyone’s health or safety Comply with the law We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law. Address workers’ compensation, law enforcement, and other government requests We can use or share health information about you: For workers’ compensation claims For law enforcement purposes or with a law enforcement official With oversight agencies for activities authorized by law Respond to covered County, State or Federal program requests We can share service information about you in response to a covered request by the county, state or federal program requests. Respond to lawsuits and legal actions We can share service information about you in response to a court or administrative order, or in response to a subpoena. Our Responsibilities We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. For more information see: xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxxxxx/xxxxxxxxx/xxxxxxxx.xxxx. Changes to the Terms of this Notice 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 (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 File a complaint if you feel your rights are violated You can complain if you feel we have violated your rights by contacting the privacy official listed above. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 000 Xxxxxxxxxxxx Xxxxxx, X.X., Xxxxxxxxxx, X.X. 00000, calling 0-000-000-0000, or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. We will not to contact retaliate against you againfor filing a complaint. Initial Here __________ Self-Directed Services Participant Agreement THIS AGREEMENT is made effective on ____________________________________ , by and between and ___________________________________________ , Participant Employer or Managing Party.

Your Rights. When it comes to your health information, you You have certain rights. This section explains your rights and some of our responsibilities to help you.  the right to: • Get an electronic or paper 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 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 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 • 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. • 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 • You can ask us to correct health 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.  • Request confidential 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. • We will say “yes” to all reasonable requests.  Ask us to limit what we use or share • You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care. • 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. We will say “yes” unless a law requires us to share that information.  Get a list of those with whom we’ve shared information • You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. • We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.  Get a copy of this privacy notice You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.  Choose someone to act for you • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. • 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 • You can complain if you feel we have violated your rights by contacting our Clinical Director us at Arizona Psychology and Privacy OfficerWellness 0000 X Xxxxx Xx XXX 000 Xxxxxxx, Xxxxx XxxxxxXX 00000, LCSW calling 000-000-0000, or emailing at 314.336.1041xxxxx@xxxxxxxxxxxxxxxxx.xxx You may also contact the Ethics Committee of the Arizona Psychological Association (AzPA) for further information. • You can also 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 10- 000-877- 000-0000, or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. • We will not retaliate against you for filing a complaint. 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 • Include your information in a hospital directory In these cases cases, we never share your information unless you give us written permission:  • Marketing purposes  • Sale of your information • Most sharing of psychotherapy notes  In Our Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the case of fundraisingfollowing 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, we may improve your care, and contact you when necessary. Example: We use health information about you to manage your treatment and services. Bill for fundraising effortsyour 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, but 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 not 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 contact you againthe 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.

Your Rights. When it comes to your health information, you You have certain rights. This section explains your rights and some of our responsibilities to help you.  the right to: • Get an electronic or paper 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 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 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 • 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. • 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 • You can ask us to correct health 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.  Request confidential 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. • We will say “yes” to all reasonable requests.  Ask us to limit what we use or share • You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care. • 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. We will say “yes” unless a law requires us to share that information.  Get a list • 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 those 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 whom we’ve shared information 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. • 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. • We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.  Get a copy of this privacy notice You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.  Choose someone to act for you • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. • 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 • You can complain if you feel we have violated your rights by contacting our Clinical Director and Privacy Officer, Xxxxx Xxxxxx, LCSW at 314.336.1041us using the information on page 1. • You can also 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 10- 000-877- 000-0000, or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. • We will not retaliate against you for filing a complaint. 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 • Include your information in a hospital directory In these cases cases, we never share your information unless you give us written permission:  • Marketing purposes  • Sale of your information • Most sharing of psychotherapy notes  In the case of fundraising, we : • 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. 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 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. 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 You can ask us to correct health 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.  • Request confidential 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. We will say “yes” to all reasonable requests.  • Ask us to limit what we use or share You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care. 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. We will say “yes” unless a law requires us to share that information.  • Get a list of those with whom we’ve shared information You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.  • Get a copy of this privacy notice You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.  • Choose someone to act for you If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. 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 You can complain if you feel we have violated your rights by contacting 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 Services Office for Civil Rights by sending a letter to 000 Xxxxxxxxxxxx Xxxxxx, X.X., Xxxxxxxxxx, X.X. 00000, calling 1-877- 000-0000, or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. We will not retaliate against you for filing a complaint. 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.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 a copy of your paper or electronic medical 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. ⮚ 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 Correct your paper or electronic medical record ⮚ You can ask us to correct health 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.  Request confidential communications 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. ⮚ We will say “yes” to all reasonable requests.  Ask us to limit what the information we use or share ⮚ You can ask us not to use or share certain health information for treatment, payment, or our operations. ⮚ We are not required to agree to your request, and we may say “no” if it would affect your care. ⮚ 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. ⮚ 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 ⮚ 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. ⮚ We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.  Get a copy of this privacy notice ⮚ You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will promptly provide you with a paper copy promptlycopy.  Choose someone to act for you ⮚ If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. ⮚ 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 ⮚ You can complain if you feel that we have violated your rights by contacting our Clinical Director and Privacy Officer, Xxxxx Xxxxxx, LCSW at 314.336.1041us using the information in this notice. ⮚ You can also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to to: U.S. Department of Health and Human Services Office for Civil Rights 000 Xxxxxxxxxxxx Xxxxxx, X.X., X.X. Xxxxxxxxxx, X.X. 00000, calling 100000 Or by calling: 0-877- 000-0000, 000-0000 or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. xxxxx://xxx.xxx.xxx/civil-rights/filing-a-complaint/index.html ⮚ We will not retaliate against you for filing a complaint. 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.

Your Rights. When it comes You have the right to: • Get a copy of your paper mental health record • Correct your paper mental health record • Request confidential communication • Ask us to limit the information we share 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 We may use and share your information as we: • Treat you • Bill for your services • Help with public health informationand safety issues • Comply with the law • 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 • Provide mental health care • Market our services • Work with a medical examiner or funeral director • Address worker’ compensation, you have certain rights. law enforcement, and other government requests • Respond to lawsuit and legal actions This section explains your rights and some of our responsibilities to help you.  Get an electronic or paper copy of your medical record • You can ask to see or get an electronic or a paper copy of your medical mental health record and other health information we have about you. Ask us how to do this. • We will provide a copy or a summary of your mental health information, usually within 30 15 days of your request. We may charge a reasonable, cost- based fee.  Ask us to correct your medical record • You can ask us to correct mental health 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.  Request confidential 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. • We will say “yes” to all reasonable requests.  Ask us to limit what we use or share • You can ask us not to use or share certain mental health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care. • 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. We will say “yes” unless a law requires us to share that information.  Get a list of those with whom we’ve shared information • You can ask for a list (accounting) of the times we’ve shared your mental health information for six years prior to the date you ask, who we shared it with, and why. • We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.  Get a copy of this privacy notice • You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.  Choose someone to act for you • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your mental health information. • 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 • You can complain if you feel we have violated your rights by contacting our Clinical Director and Privacy Officer, Xxxxx Xxxxxx, LCSW at 314.336.1041us using the information on page 1. • You can also 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 10-877- 000-000-0000, or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. We will not retaliate against you for filing a complaint. 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 We typically use or share your mental health information in the case of fundraising, we may contact following ways: • Treat you for fundraising efforts, but you We can tell us not to contact you againuse your mental 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 • 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. • 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 • You can ask us to correct health 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.  Request confidential 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. • We will say “yes” to all reasonable requests.  Ask us to limit what we use or share • You can ask us not to use or share certain health information for treatment, payment, or our operations. • We are not required to agree to your request, and we may say “no” if it would affect your care. • 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. • We will say “yes” unless a law requires us to share that information.  Get a list of those with whom we’ve shared information • You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. • We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.  Get a copy of this privacy notice • You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.  Choose someone to act for you • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. • 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 • You can complain if you feel we have violated your rights by contacting our Clinical Director and Privacy Officer, Xxxxx Xxxxxx, LCSW at 314.336.1041us using the information on page 1. • You can also 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 10-877- 000-000-0000, or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. • We will not retaliate against you for filing a complaint. 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 • Include your information in a hospital directory • 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:  • Marketing purposes  • Sale of your information • Most sharing of psychotherapy notes  In the case of fundraising, we : • We may contact you for fundraising efforts, but you can tell us not to contact you againxxxxx.Xxx do we typically use or share your health information? 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 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. 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 • 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. • 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 • You can ask us to correct health 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.  Request confidential 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. • We will say “yes” to all reasonable requests.  Ask us to limit what we use or share • You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care. • 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. We will say “yes” unless a law requires us to share that information.  Get a list of those with whom we’ve shared information • You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. • We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.  Get a copy of this privacy notice You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.  Choose someone to act for you • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. • 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 • You can complain if you feel we have violated your rights by contacting our Clinical Director and Privacy Officer, Xxxxx Xxxxxx, LCSW at 314.336.1041us using the information on page 1. • You can also 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 10-877- 000-000-0000, or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. • We will not retaliate against you for filing a complaint. 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 • Include your information in a hospital directory If you are not able to tell us your preference, for example if you are unconscious, we never may go ahead and share your information unless you give us written permission:  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. • Marketing purposes  • Sale of your information • Most sharing of psychotherapy notes  In How do we typically use or share your health information? We typically use or share your health information in the case of fundraising, we may contact you for fundraising efforts, but you following ways. • We can tell us not to contact you againuse your health information and share it with other professionals who are treating you.