PsyCare

DEMOGRAPHIC INFORMATION

PATIENT NAME * SEX AGE * PATIENT DATE OF BIRTH (DOB) * ADDRESS * CITY * STATE * ZIP CODE * COUNTY * SOCIAL SECURITY NUMBER * PHONE * LANGUAGE * RACE/ETHNICITY SCHOOL NAME GRADE TEACHER PRINCIPAL MARITAL STATUS OF PARENTS * FATHER NAME FATHER DATE OF BIRTH FATHER SOCIAL SECURITY NUMBER FATHER PHONE FATHER EMPLOYER NAME FATHER EMPLOYER PHONE MOTHER NAME MOTHER DATE OF BIRTH MOTHER SOCIAL SECURITY NUMBER MOTHER PHONE MOTHER EMPLOYER NAME MOTHER EMPLOYER PHONE NAMES AND AGES OF HOUSEHOLD MEMBERS IN CASE OF EMERGENCY NAME RELATIONSHIP ADDRESS PHONE LEGAL GUARDIAN NAME LEGAL GUARDIAN PHONE PRIMARY INSURANCE NAME * ID# * GROUP # SUBSCRIBER'S NAME * SOCIAL SECURITY NUMBER * DATE OF BIRTH * SUBSCRIBER'S ADDRESS * CITY * STATE * ZIP * SECONDARY INSURANCE NAME ID # GROUP # SUBSCRIBER'S NAME SOCIAL SECURITY NUMBER DATE OF BIRTH SUBSCRIBER'S ADDRESS CITY STATE ZIP PATIENT/GUARDIAN'S NAME * DATE *

PHYSICAL HEALTH SCREENING

WEIGHT HEIGHT PRIMARY CARE PHYSICIAN DATE OF LAST VISIT TO PRIMARY CARE PHYSICIAN DATE OF LAST COMPLETE PHYSICAL EXAMINATION CURRENT PHYSICAL SYMPTOMS, PAST AND CURRENT MEDICAL PROBLEMS INCLUDING INFECTIOUS AND COMMUNICABLE DISEASES ALLERGIES CURRENT MEDICATIONS PHARMACY NAME PHARMACY PHONE PHARMACY LOCATION PLEASE LIST ANY PHYSICAL SYMPTOMS THAT HAVE DEVELOPED SINCE YOUR LAST VISIT TO YOUR DOCTOR OR THAT YOU HAVE NOT PREVIOUSLY DISCUSSED WITH YOUT DOCTOR IF UNDER 18, ARE IMMUNIZATIONS UP-TO-DATE? PATIENT/GUARDIAN NAME * DATE *

PCP RELEASE OF INFORMATION

PSYCARE INC. STRONGLY RECOMMENDS THAT THE PATIENT AUTHORIZE THE EXCHANGE OF INFORMATION BETWEEN PSYCARE AND THE PATIENTS PRIMARY CARE PHYSICIAN (PCP) FOR THE PURPOSE OF APPROPRIATE COORDINATION OF CARE. THE PCP MAY HAVE IMPORTANT MEDICAL INFORMATION THAT WILL ASSIST WITH ASSESSMENT AND TREATMENT PLANNING. LIKEWISE, YOUR PCP CAN BEST SERVE YOU BY BEING FULLY INFORMED REGARDING THE CARE YOU RECEIVE AT PSYCARE.

PLEASE REVIEW THE OPTIONS AND CHECK YOUR CHOICE. * PCP NAME PCP ADDRESS OTHER INSTRUCTIONS/LIMITATIONS TO THIS AUTHORIZATION: NAME OF PATIENT OR GUARDIAN * DATE *

FEES, TEXT, AND EMAIL POLICY

FEES: The charge for the initial diagnostic interview (90791) is $255. The fee for the subsequent standard session (90837, est. 55 min) is $215. The intermediate session (90834, est. 40 min.) is $145, and brief session (90832, est. 25 min) is $110. The fee for the initial psychiatric evaluation session (90792) is $280. Subsequent medication management sessions are charged in accordance with level of complexity or time, according to AMA CPT-Code standards (99211--$35 (nurse); 99212--$80; 99213--$130; 99214--$180; 99215--$250). The fees for psychological testing and for required reports are based upon the time requirements, with a $170 charge for each hour utilized. Charges for completion of forms are $8 per 5 minutes required. Fees for specialized forensic services must be established with the clinician.

MISSED APPOINTMENTS OR LATE CANCELLATIONS: There will be no charge for appointments cancelled at least 24 hours before the scheduled appointment time. Due to the nature of psychological and psychiatric services, payment for the time reserved is necessary for late cancellations, (less than 24 hours prior to the scheduled appointment), and missed appointments. Unlike many professional practices which allow ?overbooking? and brief visits, your appointment means that you have reserved a significant amount of professional time. This is time that, for practical purposes, is lost and cannot be made up if the appointment is cancelled late. It is also time that may have been utilized for the benefit of another person with the proper advanced cancellation. Therefore, $100 will be charged for missed appointments with no prior notification, and $70 will be charged for late cancellations. These are charges that are not covered by health insurance.

INSURANCE COVERAGE: PsyCare has agreed to contractual arrangements with many insurance or managed care companies, as well as Medicare and Medicaid. The terms of these contractual agreements, which typically include allowed charges, will supersede the above fee schedule. PsyCare will make reasonable efforts to determine your specific coverage and financial responsibilities in advance of treatment; however, responsibility for the accuracy of coverage details remains yours. It is the client?s responsibility to notify PsyCare of changes in coverage; failure to notify PsyCare may result in charges to the patient due to insurance denial of payment. You will need to provide PsyCare with the necessary information describing your coverage, as well as your signature for authorization for PsyCare to provide information required by your insurance company. It is PsyCare?s policy that co-payments are due at the time of service. Following the processing of the insurance claim, the insurance company typically provides an Explanation of Benefits (EOB), which identifies the patient balance due for the service, such as an amount applied to the deductible. This amount will then be due in full.

INTEREST, LATE FEES AND COLLECTION CHARGES: There is no interest charge for accounts in good standing. However, overdue accounts (accounts with patient responsibility not paid within 20 days of account statement) will be charged a $14 re-billing fee. If collection efforts become necessary, collection costs, court costs and legal fees will be added to the account balance.

PAYMENT: Cash, checks, MasterCard and Visa accepted. There will be a $30 charge for a check returned due to insufficient funds. Under special circumstances, an individualized payment plan may be established with the Accounts Manager, as follows:

All charges are based upon the current usual and customary rates for mental health services. If you have any questions, please don?t hesitate to ask. I have read and agree to the arrangements documented above. I have been offered a copy of this form.

TEXT OR EMAIL APPOINTMENT REMINDERS: To help remember appointments and reduce the number of missed appointments, you can be sent a reminder via text or email. No HIPAA related information will be sent. I authorize PsyCare to convey appointment reminders by phone, email or text. I understand that my contact information will remain confidential. I agree to the terms and conditions provided by PINGER (www.pinger.com/content/company/termsconditions.html), and I understand that I have the option to stop reminders at any time by speaking directly with a PsyCare staff member.

EMERGENCIES AND AFTER-HOURS CARE: Your therapist may be reached at one of the PsyCare offices. Emails should not be used for therapy related information. He or she will make every effort to return messages within 24 hours; however, he or she may not always be able to do that. Current clients will be notified during sessions of upcoming travel or vacation. If you have an emergency, you should go directly to a hospital emergency department or call 911. The National Suicide Prevention Lifeline number is 1-800-273-8255. Emergencies are urgent situations and require your immediate action.

CELL PHONE EMAIL ADDRESS PATIENT/GUARDIAN NAME *

Electronic Service Delivery Informed Consent

Electronic Service Delivery is defined as mental health therapy in any form offered or rendered primarily by electronic or technology assisted approaches when the mental health provider and the client are not located in the same place during delivery of services. While working with your provider you will always have the opportunity to ask any questions that you have about the therapy, electronic communications in general, and other issues involving your therapy. Your provider will also assess your ability to handle computers and the internet, so that you and he or she may work in this way. As a client receiving mental health services through electronic service delivery methods, you should understand:

1) This service is provided by technology (including but not limited to video, phone, text, and email) and may or may not involve direct, face to face, communication. There are benefits and limitations to these types of services. You will need access to, and familiarity with, the appropriate technology to participate in the service provided. Exchange of information may not be direct, and any paperwork exchanged will likely be exchanged through electronic means or through postal delivery. Your provider will assess whether or not therapy through means of electronic service delivery is appropriate for addressing your issues and whether or not you have the knowledge and skills to use the technology involved.

2) As a provider licensed in Ohio, your provider may only deliver services to residents or people located in Ohio. If you plan on leaving Ohio for any length of time in the future, please let your provider know as soon as possible so that you and he or she can make proper arrangements for future work or referrals, as appropriate. If you are going to be out of state during therapy, then your provider will have to comply with the licensing laws of the state where you will be located.

3) If a need for direct, face to face services arises, it is your responsibility to contact providers in your area, or to contact this office for a face to face appointment. You understand that an opening may not be immediately available.

You may decline any electronic service delivery service at any time without jeopardizing your access to future care, services, and benefits.

4) These services rely on technology, which allows for greater convenience in service delivery. There are risks in transmitting information over the internet or through other electronic services that include, but are not limited to, breaches of confidentiality, theft of personal information, and disruption of service due to technical difficulties. Your provider and you will regularly reassess the appropriateness of continuing to deliver services through the use of technology. When using these services you agree to accept the risks involved with the unencrypted exchange of information, if it is provided in that way.

5) Your provider will need to verify your identity in a face to face meeting, which may be via video/audio electronically and then at subsequent sessions. At the initial session you and your provider will address imposter concerns. You should be aware that misunderstandings are possible with telephone, text-based modalities (e.g., email), and real-time internet chat, since non-verbal cues are relatively lacking. Even with video chat software, since bandwidth may be limited and images may lack detail, misunderstandings may occur. Your provider is an observer of human behavior. He or she will gather information from body language, vocal inflection, eye contact, and other non-verbal cues. Cultural differences and how they affect non-verbal cues may also be involved and your provider will assess whether or not this type of therapy is appropriate for your cultural experiences, your environment, and your therapeutic needs. If work is being done with families or groups with different levels of technology competence, power dynamics will be acknowledged. Please let your provider know if you have any type of audio/visual or cognitive impairment prior to beginning therapy. If you have never engaged in online counseling, you need to have patience with the process and request clarification if you believe that you are not being understood by your provider or you do not understand something that your provider says. He or she will regularly review whether or not electronic service delivery is meeting the goals of therapy. Your provider will also discuss with you how to handle disruptions in services and all methods of delivering services that are compliant with commonly accepted standards of technology safety and security at the time at which services are rendered.

6) In emergencies, in the event of disruption of service, or for routine or administrative reasons, it may be necessary to communicate by other means:

a) In emergency situations: If it is an imminent situation that requires face-to-face contact call 911 or go to the nearest emergency room. If it can be managed over the phone, you can call your provider, but if your provider does not respond immediately or within a short period of time, you should contact local emergency services (for example, call 911 or go to your local hospital?s emergency room, or call the National Suicide Prevention Hotline number -1-800-273-8255.) Also, other local hotline crisis phone numbers may be available to call, and you can check on the internet to find those.

b) Should service be disrupted: Try to regain contact using the same medium. If that does not work, attempt to make contact using text or e-mail. Your provider will also make every effort to regain contact. If service is disrupted during a therapy session before the pre-agreed time frame has ended, you will have the opportunity to use the remaining time as soon as contact is made. If contact is not re-established within one hour, you will have the choice to end the session and be charged a pro-rated amount or allowed to schedule an additional session to use the remaining time.

c) For other communications: Your provider and you may agree to communicate via a phone call, videoconferencing, e-mail, text, fax, or mailed letters.

(7) The potential benefits of online counseling include flexibility in scheduling and allowing you to engage in counseling outside of the office, which eliminates issues like transportation and other psycho-social barriers that might make it difficult for you to handle in a traditional office setting. The provision of online counseling may include risks related to the technology used, the distance between you and your provider, and issues related to timeliness. For example, the potential risk of confidentiality may pertain to your accessing the internet from public locations. You should consider the visibility of your screen and being overheard when in public settings. It is recommended that you be in a private setting when engaging in online counseling. You should also always use strong passwords to protect any information shared with your provider. Never use a work computer for therapy as your employer may have access to the information shared in electronic communications. Be cautious when using a shared network with others.

(8) Although the internet provides the appearance of anonymity and privacy in counseling, privacy is more of an issue online than it is in person. You are responsible for confidentiality in your own environment, including securing your hardware, internet access points, chat software, email, and passwords. Please develop passwords that are appropriate and strong and not use auto-fill for user names or passwords. Although your provider will take steps to protect your information, he or she will have policies in effect to notify you of a breach of any of your confidential information which is required to be reported to you.

(9) Your provider may utilize alternative means of communication in the following circumstances: if you do not respond to text, your provider may call. If you do not respond to a call, your provider may follow up with text or e-mail. If you do not respond to a call, text, or e-mail, your provider may follow up with a mailed letter. In case of emergency (or concerns over your welfare), your provider may contact your emergency contact if you have provided one.

(10) Your provider will attempt to respond to communications and routine messages within 48 hours if he or she is available.

(11) Governor DeWine in March 2020 issued an emergency order mandating that most insurance companies in Ohio reimburse for telehealth therapy, so there may be insurance coverage for therapy sessions delivered through technology in Ohio. However, you should check with your insurance company to determine if they will reimburse you for electronic service delivery sessions. If insurance does not cover reimbursement, then you agree to pay the fee for the service.

(12) You need to take the following precautions to ensure that your communications are directed only to your provider or other individuals: Ensure that you use the correct e-mail address, telephone number, skype or online name, fax number, and physical address to contact the appropriate individuals. Only leave voice messages after ensuring that the correct phone number was dialed and the voicemail introduction identifies the correct individual.

(13) Your communications exchanged with your provider, if capable of being put into written form, will be stored in the following manner: e-mails, texts, and other electronic communication relevant to treatment will be printed and kept in your file. Mailed letters and documents will also be kept in your file. Notes outlining electronic service delivery treatment sessions will be written and kept in your file. Your file will be kept in a locked file cabinet or stored electronically and will be accessible only by those who require or are allowed access and will be available to you or someone named by you for the length of time required under Ohio law. Your provider will not record sessions without first discussing it with you and obtaining your permission to do that. Please see your provider?s regular Informed Consent form for information on access to your records, including who will have access to them.

(14) The laws, ethics and professional standards that apply to in-person therapeutic services also apply to services delivered by electronic means. This document does not replace other agreements, contracts, or documentation of informed consent covering other issues. If you want licensing information on your provider, you can find it at one of the licensing board websites. Psychology Board statutes, rules and other helpful information may be found at www.psychology.ohio.gov, the Counselor, Social Worker & Marriage and Family Therapist Board?s website may be found at www.cswmft.ohio.gov, the Chemical Dependency Professionals Board?s website may be found at www.ocdp.ohio.gov, the Ohio State Medical Board?s website may be found at www.med.ohio.gov, and the Nursing Board?s website is found at www.nursing.ohio.gov.

Acknowledgment of Informed Consent to Treatment via Electronic Service Delivery Means:

You voluntarily agree to receive mental health assessment, care, treatment, or services and authorize your provider to provide such care, treatment or services as are considered necessary and advisable via electronic service delivery means.

By signing this Electronic Service Delivery Informed Consent, you, the undersigned client, acknowledge that you have both read and understood all the terms and information contained herein and you agree to be bound by the provisions in this agreement. Ample opportunity has been offered to you to ask questions and seek clarification of anything unclear to you. If a minor is the client, you are signing on behalf of the minor as the authorized parent/guardian. (Information on Minor rights will be shared with the minor.)

You also acknowledge that you have received a copy of the regular Informed Consent and Notice of Privacy Practices for the practice listed at the top of this form.

Client Signature: Date:

Parent(s) or Guardian Signature (for minor child or children or disabled adults)

Client Name: Signature of Parent or Legal Guardian: Date: Signature of Other Parent or Legal Guardian: Date:

Patient Rights for Minors

Below is a list of rules we follow. Please read it and ask your therapist any questions you have about it. A therapist is a specially trained person who is a good listener and can help you make your life better.

(1) We will treat you with politeness and respect.

(2) We will work with you and your parents no matter how old you are, if you are a girl or boy, the color of your skin, or if you believe in religion.

(3) We will use your help to write a plan for how we are going to help you, and your parents will see this plan and sign it.

(4) We will tell you about the good and bad that may happen if you try some new things.

(5) We will help protect you from people who are hurting you.

(6) We will allow you to say "no" to our help.

(7) We will tell you about any other ideas or places that might be good for you.

(8) We will try to maintain your confidentiality when possible, but there are a few circumstances where we may not be able to:

(a) If you tell us that someone is hurting your body physically or sexually, we will report that to people who can help you (Children Services Board).

(b) If you tell us you are going to harm yourself, we will need to tell your family.

(c) If you tell us you are going to harm someone, we will report it to people who can help.

(d) Your parents/guardians typically have access to your records, if they choose, unless they are blocked by court order from requesting them.

(e) If a court orders that we send it your records, we will be required to send them.

(9) If you have complaints about us or don't like something that is happening while you are here, we will listen and talk about it. We will make changes if they are good for you and if they are possible.

I have read or had this form read to me, and I fully understand what it means.

Signature of Patient: Date: Signature of Parent or Legal Guardian: Date:

Pediatric Symptom Checklist

Please mark the option that best describes your child:

1. Complains of aches and pains 2. Spends more time alone 3. Tires easily, has little energy 4. Fidgety, unable to sit still 5. Has trouble with teacher 6. Less interested in school 7. Acts as if driven by a motor 8. Daydreams too much 9. Distracted easily 10. Is afraid of new situations 11. Feels sad, unhappy 12. Is irritable, angry 13. Feels hopeless 14. Has trouble concentrating 15. Less interested in friends 16. Fights with other children 17. Absent from school 18. School grades dropping 19. Is down on themselves 20. Visits the doctor with the doctor finding nothing wrong 21. Has trouble sleeping 22. Worries a lot 23. Wants to be with you more than before 24. Feels they are bad 25. Takes unnecessary risks 26. Gets hurt frequently 27. Seems to be having less fun 28. Acts younger than children their age 29. Does not listen to rules 30. Does not show feelings 31. Does not understand other people's feelings 32. Teases others 33. Blames others for their troubles 34. Takes things that do not belong to them 35. Refuses to share

Columbia Impairment Scale

Please select the number that you think best describes the child or youth?s situation:

In general, how much of a problem do you think they have with:

...getting into trouble? ...getting along with (you/their mother/mother figure). ...getting along with (you/their father/father figure). ...feeling unhappy or sad?

How much of a problem would you say they have:

...with their behavior at school (or their job)? ...with having fun? ...getting along with adults other than (you and/or their mother/father)?

How much of a problem do they have:

...with feeling nervous or afraid? ...getting along with their sisters/brothers? ...getting along with other kids their age?

How much of a problem would you say they have:

...getting involved in activities like sports or hobbies? ...with their school work (doing their job)? ...with their behavior at home?

PsyCare, Inc. HIPAA Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

The mission of PsyCare is to enhance and promote the mental and emotional well-being and optimal social functioning of all persons. This mission is accomplished by providing a comprehensive and integrated continuum of outpatient mental health and related services. In conjunction with the provision of such services, at times it may be necessary for us to use and to disclose your protected health information (PHI). PHI refers to information in your health record that could identify you. It includes information about your symptoms, test results, diagnosis, treatment, and related medical information.

PsyCare is required by law to maintain the privacy of your PHI and to provide you with notice of the legal duties and privacy practices regarding PHI and to notify you following a breach of unsecured PHI. We understand that your health information is highly personal, and we are committed to safeguarding your privacy.

I. Disclosure of Your PHI Without Your Authorization

This Notice sets forth different reasons for which we may use and disclose your PHI. The Notice does not list every possible use and disclosure; however, all the reasons for which we are permitted to use and disclose your PHI are listed. The amount of health information used or disclosed will be limited to information that excludes most direct identifiers, such as name, address, and Social Security number, unless more information is needed. If additional information is needed, it will be limited to the ?minimum necessary? to accomplish the purpose of the use or disclosure.

To You: PsyCare may disclose your PHI to you, the individual who is the subject of the information.

Treatment, Payment, & Health Care Operations: PsyCare may use or disclose your PHI for treatment, payment, and health care operations purposes. Treatment is when we provide, coordinate, or manage your health care and other services related to your care. An example would be when we consult with another health care provider, such as your family physician or specialist. Payment is when we obtain reimbursement for your health care. Examples of payment are when we disclose your PHI to your health insurer to obtain reimbursement for our services to you or to determine eligibility or coverage. Health Care Operations are activities that relate to the performance and operation of our practice. Examples of this are quality improvement activities, business-related matters (such as audits and administrative services), case management, and care coordination. Use applies only to activities within our practice, such as sharing, applying, utilizing, examining, and analyzing information that identifies you. Disclosure applies to activities outside PsyCare?s practice, such as releasing, transferring, or providing access to information about you to other parties.

Incidental Use and Disclosure: PsyCare may use of disclosure your PHI as a result of, or as ?incident to,? an otherwise permitted use or disclosure, as long as it has adopted reasonable safeguards as required by HIPAA and the information being shared is limited to the ?minimum necessary.?

Where Required by Law: PsyCare may use and disclose your PHI as required by law, including, but not limited to, statute, regulation, or court order.

Public Health Activities: PsyCare may disclose your PHI to: (1) public health authorities authorized by law to collect or receive such information for preventing or controlling disease, injury, or disability and to public health or other government authorities authorized to receive reports of child abuse and neglect; (2) entities subject to FDA regulation regarding FDA regulated products or activities for purposes such as adverse event reporting, tracking of products, product recalls, and post-marketing surveillance; (3) individuals who may have contracted or been exposed to a communicable disease when notification is authorized by law; and (4) employers, regarding employees, when requested by employers, for information concerning a work-related illness or injury or workplace related medical surveillance, because such information is needed by the employer to comply with the Occupational Safety and Health Administration (OHSA), the Mine Safety and Health Administration (MHSA), or similar state law.

Victims of Abuse, Neglect or Domestic Violence: In situations involving abuse, neglect, or domestic violence, PsyCare may disclose your PHI to appropriate government authorities.

Health Oversight Activities: PsyCare may disclose your PHI to health oversight agencies for purposes of legally-authorized health oversight activities, such as audits and investigations necessary for oversight of the health care system and government benefit programs.

Judicial and Administrative Proceedings: PsyCare may disclose your PHI in a judicial or administrative proceeding if the request for the information is through an order from a court or administrative tribunal. Such information may also be disclosed in response to a subpoena or other lawful process if certain assurances regarding notice to the individual or a protective order are provided.

Law Enforcement Purposes: PsyCare may disclose your PHI to law enforcement officials for law enforcement purposes under the following six circumstances, and subject to specified conditions: (1) as required by law (including court orders, court-ordered warrants, subpoenas) and administrative requests; (2) to identify or locate a suspect, fugitive, material witness, or missing person; (3) in response to a law enforcement official?s request for information about a victim or suspected victim of a crime; (4) to alert law enforcement of a person?s death, if PsyCare suspects that criminal activity caused the death; (5) when PsyCare believes that PHI is evidence of a crime that occurred on its premises; and (6) by PsyCare in a medical emergency not occurring on its premises, when necessary to inform law enforcement about the commission and nature of a crime, the location of the crime or crime victims, and the perpetrator of the crime.

Decedents: PsyCare may disclose your PHI to funeral directors as needed, and to coroners or medical examiners to identify a deceased person, determine the cause of death, and perform other functions authorized by law.

Cadaveric Organ, Eye, or Tissue Donation: PsyCare may use or disclose PHI to facilitate the donation and transplantation of cadaveric organs, eyes, and tissue.

Research: Research is any systematic investigation designed to develop or contribute to generalized knowledge. PsyCare may use and disclose your PHI for research purposes, provided that it obtains either: (1) documentation that an alteration or waiver of individuals? authorization for the use or disclosure of PHI about them for research purposes has been approved by an Institutional Review Board or Privacy Board; (2) representations from the researcher that the use or disclosure of PHI is solely to prepare a research protocol or for similar purpose preparatory to research, that the researcher will not remove any PHI from PsyCare, and that PHI for which access is sought is necessary for the research; or (3) representations from the researcher that the use or disclosure sought is solely for research on PHI of decedents, that the PHI sought is necessary for the research, and, at the request of PsyCare, documentation of the death of the individuals about whom information is sought.

Serious Threat to Health or Safety: PsyCare may disclose your PHI if it believes such disclosure is necessary to prevent or lessen a serious and imminent threat to a person or the public, when such disclosure is made to someone they believe can prevent or lessen the threat (including the target of the threat).

Essential Government Functions: PsyCare may disclosure your PHI for certain essential government functions, including assuring proper execution of a military mission, conducting intelligence and national security activities that are authorized by law, providing protective services to the President, making medical suitability determinations for U.S. State Department employees, protecting the health and safety of inmates or employees in a correctional institution, and determining eligibility for or conducting enrollment in certain government benefit programs.

Workers? Compensation: PsyCare may disclose your PHI as authorized by, and to comply with, workers? compensation laws and other similar programs providing benefits for work-related injuries or illnesses.

Limited Data Set: A limited data set is PHI from which certain specified direct identifiers of individuals and their relatives, household members, and employers have been removed. PsyCare may disclose for research, health care operations, and public health purposes, a limited data set, provided the recipient of the limited data set enters into a data use agreement promising specified safeguards for PHI within the limited data set.

II. Disclosure of PHI With Your Authorization

In all other instances (including most uses or disclosures of PHI consisting of psychotherapy notes), PsyCare may use or disclose your PHI only with your authorization. ?Authorization? is written permission that allows PsyCare to disclosure specific PHI. You may revoke all such authorizations at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that?1) we have relied on that authorization or 2) if the authorization was obtained as a condition of obtaining insurance coverage and the law provides the insurer the right to contest the claim under the policy.

We will obtain a written authorization for any use or disclosure of psychotherapy notes, except: (1) to carry out the following treatment, payment, or health care operations: use by us for treatment; use or disclosure by us for our own training programs in which students, trainees, or practitioners in mental health learn under supervision to practice or improve their skills in group, joint, family, or individual counseling; or use or disclosure by us to defend ourselves in a legal action or other proceeding brought by you; and (2) a use or disclosure that is: required by the Secretary of the United States Department of Health and Human Services when the Secretary is investigating or determining our compliance with the HIPAA privacy rule; permitted by law; for health oversight with respect to the oversight of our operations; to a coroner or medical examiner for the purpose of identifying a decedent; or to avert a serious threat to health or safety.

III. Disclosures That Will Not Be Made

Please note that we do not use your PHI for marketing or fundraising efforts. We do not sell your PHI. We also do not use or disclose your genetic information PHI for underwriting purposes, which is prohibited by the Genetic Information Nondiscrimination Act (GINA) of 2008.

IV. Your Rights under HIPAA

Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of your PHI; however, we are not required to agree to a restriction at your request except for restrictions for any disclosures to be made to a health plan for payment or health care operations functions (but not for treatment purposes) involving a health care item or service for which you have paid us out of pocket in full.

Right to Receive Confidential Communications by Alternative Means and at Alternative Locations: You have the right to request and receive confidential communication of PHI by alternative means and at alternative locations. For example, you may not want a family member to know that you are receiving services at PsyCare. Upon your request, we will send your statements to another address.

Right to Inspect and Copy: You have the right to inspect or obtain a copy (or both) of PHI records used to make decisions about you for as long as the PHI is maintained in the record. If the we maintain your PHI in an electronic format (including in an electronic health record), you have a right to obtain a copy of such information in an electronic format and, if you so choose, direct us to transmit such copy directly to another entity or person. We may deny your request to inspect and copy your PHI in certain limited circumstances. In some circumstances, you may request that the denial be reviewed.

Right to Amend: You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. On your request we will discuss with you the details of the amendment process. We may accept or deny your request.

Right to an Accounting: Generally, you have the right to receive an accounting of disclosures of PHI for which you have not provided either consent or authorization (as described in Section III of this Notice). You also have the right to request an accounting of disclosures of your PHI through an electronic health record made by us to carry out our payment activities or health care operations within the past three years from the date of your request. On your request, we will discuss with you the details of the accounting process.

Right to a Paper Copy: You have the right to obtain a paper copy of the notice from PsyCare upon request, even if you have agreed to receive the notice electronically.

Right to Receive Notification: You are entitled to receive notification from us if the confidentiality of any of your PHI maintained in an unsecured form is compromised.

V. PsyCare?s Duties Under HIPAA

We are required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI.

We reserve the right to change the privacy policies and practices described in this notice. We are required to abide by the terms currently in effect, unless we notify you of such changes.

We reserve the right to change the terms of this notice and to make the provisions of the new notice effective for all PHI that we maintain. If we revise our policies and procedures that will affect your PHI, we will send a notice of these changes to you by regular mail to your last known address that we have on file for you.

VI. Questions and Complaints

If you have questions about this notice, disagree with our decision about access to your records, or have other concerns about your privacy rights, you may contact the Privacy Officer for PsyCare, in writing, at PsyCare, 2980 Belmont Avenue, Youngstown, Ohio, 44505, or by phone at 330-759-2310.

If you believe that your privacy rights have been violated and wish to file a complaint, you may send your written complaint to the Privacy Officer at PsyCare, 2980 Belmont Avenue, Youngstown, Ohio, 44505.

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services at 200 Independence Avenue, SW, in Washington, D.C., 20201.

We will not retaliate against you for exercising your right to file a complaint.