ALCOTT CENTER FOR MENTAL HEALTH SERVICES NOTICE OF PRIVACY PRACTICES

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

WHO WILL FOLLOW THIS NOTICE

This Notice describes the Alcott Center for Mental Health Services' (Alcott Center) practices and that of:

• Al1 employees, staff and other Alcott Center personnel.

• Any volunteers we allow to serve you while you are at the agency.

OUR PLEDGE REGARDING MEDICAL INFORMATION

We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive at the agency. We need this record to provide you with quality care and to comply with certain legal requirements. This Notice applies to all of the records of your care generated by the Alcott Center for Mental Health Services. As required and when appropriate, we will ensure that the minimum necessary information is released in the course of our duties.

This Notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations regarding the use and disclosure of medical information.

We are required by law to: (1) Make sure your medical information, also known as "protected health information" or "PHI", is kept private; (2) Give you this Notice of our legal duties and privacy practices with respect to your PHI; (3) Follow the terms of the Notice that is currently in effect; and (4) Notify you in case there is an unauthorized use or disclosure of your unsecured medical information.

HOW WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION

The following categories describe different ways that we use and disclose protected health information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

For Treatment

We create a record of the treatment and services you receive at our agency. We may use your PHI to provide you with medical treatment or services. We may disclose your PHI to case managers, therapists, volunteer interns, or other agency personnel who are involved in taking care of you at the center. For example, your therapist may share PHI with your case manager in order to coordinate the different things you need, such as a psychiatrist appointment, a medical exam, or a lab test.

We also may disclose your PHI to people outside the agency who may be involved in your treatment, such as your psychiatrist, or your coordinating case manager, for coordination and management of your health care. For example, your therapist may share information with your psychiatrist about

your response to a new medication, in effort to evaluate the effectiveness of your treatment. Your mental health information may only be relayed to health care professionals outside this agency without your authorization if they are responsible for your physical or mental health care.

For Payment

We may use and disclose your PHI in order to get paid for the treatment and services we have provided you. For example, we may need to give your health plan information about a visit or treatment session you received at the agency so your health plan will pay us. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

For Health Care Operations

We may use and disclose your PHI to carry out activities that are necessary to operate our organization and to make sure that all of our clients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine medical information about many agency clients to decide what additional services the agency should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to our accountants, attorneys, student trainees and other Alcott Center personnel for review and learning purposes. We may also combine the information we have from other agencies to compare how we are doing and see where we can make improvements in the care and services we offer.

Appointment Reminders, Treatment Alternatives, and Health-Related Products and

Services

We may use and disclose your PHI to provide appointment reminders or give you information about treatment alternatives. We may also use and disclose PHI to tell you about health-related benefits or services that may be of interest to you (for example, Medi-Cal benefits).

Fundraising Activities

We may use PHI about you to contact you in an effort to raise money for our programs, services and operations. We may disclose medical information to a foundation related to the agency so that the foundation may contact you in raising money for the agency. If you do not want us to contact you for fundraising purposes, you must notify the Executive Director in writing. Please state clearly that you do not want to receive any fundraising solicitations from us.

HOW WE MAY USE AND DISCLOSE YOUR PHI WITHOUT YOUR AUTHORIZATION BUT WHICH YOU WILL HAVE OPPORTUNITY TO OBJECT

Individuals Involved in Your Care or Payment for Your Care

We may disclose your PHI to a friend or family member that you indicate is involved in your medical care or the payment for your care. In addition, we may disclose your PHI to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status, and location. You may object to this disclosure with a written request. However, if you are not

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available or are unable to agree or object, or in some emergency circumstances, we will use our professional judgment to decide whether this disclosure is in your best interest.

HOW WE MAY USE AND DISCLOSE PHI ABOUT YOU THAT DOES NOT REQUIRE YOUR AUTHORIZATION OR OPPORTUNITY TO OBJECT

As Required by Law

We will disclose your PHI when required to do so by federal, state or local law.

Workers' Compensation

We will disclose your PHI for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks

We may disclose your PHI for public health activities, such as those aimed at preventing or controlling disease, preventing injury or disability, and reporting the abuse or neglect or children, elders and dependent adults.

Health Oversight Activities

We may disclose your PHI to a health oversight agency for activities authorized by law. These oversight activities include, for-example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights.

Lawsuits and Disputes

If you are involved in a lawsuit or a dispute, we may disclose your PHI in response to a court or administrative order. We may also disclose your PHI in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request (which may include written notice to you) or to obtain an order protecting the PHI requested.

Law Enforcement

If asked to do so by law enforcement and as authorized or required by law, we may release medical information: (1) To identify or locate a suspect, fugitive, material witness, or missing person; (2) About a suspected victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement; (3) About a. death suspected to be the result of criminal conduct; (4) About criminal conduct on our premises; and (5) In case of a medical emergency, to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.

Coroners, Medical Examiners and Funeral Directors

We may release PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release PHI about clients of the agency to funeral directors as necessary to carry out their duties.

Specialized Government Functions

We may disclose your PHI to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law. We may disclose your PHI to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state, or to conduct special investigations. We may disclose PHI of military personnel and veterans

in certain situations.

Research

Under certain circumstances, we may use and disclose your PHI to medical researchers who request it for approved medical research purposes. A]] potential research projects are subject to an approval process that evaluates the project's use of PHI with the client's need for privacy of their PHI.

Inmates

If you are an inmate or under the custody of a law enforcement official, we may release your PHI to the correctional institution or law enforcement official. 'Ibis release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

Disclosure For Threats to Health and Safety

In certain circumstances, we may be required to disclose medical information to avert a serious threat to your health and safety or the health and safety of another person as required by law enforcement. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law.

HOW WE MAY USE AND DISCLOSE PHI WITH YOUR AUTHORIZATION

Other uses and disclosures of your PHI not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you provide us authorization to use or disclose your PHI, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose your PHI for the reasons covered by the authorization, except that, we are unable to take back any disclosures we have already made when the authorization was in effect, and we are required to retain our records of the care that we provided to you.

RIGHTS REGARDING YOUR PHI

You have the following rights regarding your PHI in our records:

Right to Inspect and Copy

With certain exceptions, you have the right to inspect and copy your PHI from our records. Usually, this includes treatment and billing records, but may not include some mental health information.

To inspect and copy PHI that may be used to make decisions about you, you must submit your request in writing to the Program Manager. We will provide you a form for this request. If you request a copy of your PHI, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.

We may deny your request to inspect and copy in certain circumstances. If you are denied the right to inspect and copy your PHI in our records, you may request that the denial be reviewed. With the exception of a few circumstances that are not subject to review, another licensed health care professional within Alcott Center, who was not involved in the denial, will review the decision. We will comply with the outcome of the review.

Right to Request Amendment

If you feel that your PHI in our records is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as we keep the PHI.

To request an amendment, ask for a Request to Amend Protected Health Information form, and complete and submit this form to the Program Manager. In addition, you must provide a reason that supports your request.

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend PHI that: (1) Was not created by us, unless you can provide us with a reasonable basis to believe that the person or entity that created the PHI is no longer available to make the amendment; (2) Is not part of the PHI kept by or for the agency; (3) Is not part of the PHI which you would be permitted to inspect and copy; or (4) Is accurate and complete.

If we deny your request for amendment, you have the right to submit a Statement ofDisagreement form, with a description not to exceed 250 words, with respect to any item or statement in your record you believe is incomplete or incorrect. If you clearly indicate in writing that you want this form to be made part of your medical record, we will attach it to your records and include it whenever we make a disclosure of the item or statement you believe to be incomplete or incorrect.

Right to an Accounting of Disclosures

You have the right to request an accounting of disclosures. This is a list of the disclosures we made of your PHI other than our own uses for treatment, payment and health care operations, as those functions are described above, and with other exceptions pursuant to the law.

To request this list or accounting of disclosures, ask for a Request for an Accounting of Disclosures form and complete and submit this form to the Program Manager. Your request must state a time period that may not be longer than six years and may not include dates before April 14, 2003. The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions

You have the right to request that we follow additional, special restrictions when using or disclosing your PHI for treatment, payment or health care operations. You also have the right to request that

we follow additional, special restrictions when using or disclosing your PHI to someone who is involved in your care or the payment for your health care, like a family member or friend. For example, you could ask that we not use or disclose that you are receiving services at this agency. We are not required to agree to your request. lf we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

To request restrictions, ask for a Request for Additional Restrictions on Use or Disclosure of Protected Health Information form, and complete and submit this form to the Program Manager. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.

Right to Request Confidential Communications

You have the right to request that we communicate with you about your appointments or other matters related to your treatment in a specific way or at a specific location. For example, you can ask that we only contact you at work or by mail.

To request confidential communications, ask for a Request to Receive Confidential Communications by Alternative Means or at Alternative Location form, and complete and submit this form to the Program Manager. Your request must specify how or where you wish to be contacted. We will not ask you the reason for your request. We will accommodate all reasonable requests.

Right to a Paper Copy of This Notice

You have the right to a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice.

You may obtain a paper copy of this Notice from the front desk receptionist or your case manager. You may also obtain a copy of this Notice at our website: www.alcottcenter.org.

CHANGES TO THIS NOTICE

We reserve the right to change the terms of this Notice. We reserve the right to make the revised or changed Notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current Notice in the reception area and other visible locations in the facility. The Notice wi11 contain on the last page, bottom left hand comer, the effective date. If we change our Notice, you may obtain a copy of the revised Notice by visiting our website at www.alcottcenter.org, or you may request one from your case manager.

TO GET MORE INFORMATION OR TO FILE A COMPLAINT

If you believe your privacy rights have been violated, you may file a written complaint with our Privacy Officer. You also may file a written complaint with the U.S. Department of Health and Human Services at Office of Civil Rights, DHHS, 90 7th Street, Suite 4-100, San Francisco, CA, 94103. You will not be penalized or retaliated against for filing a complaint. To file a complaint with us, or if you have comments or questions regarding our privacy practices, contact:

Alcott Center for Mental Health Services

Privacy Officer

1433 South Robertson Blvd. Los Angeles, California 90035 (310) 785-2121

Effective Date: September 23, 2013