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

The Health Insurance Portability & Accountability Act of 1996 (“HIPAA” or the “Act”) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, or paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. “HIPAA” provides penalties for covered entities that misuse personal health information. As required by “HIPAA”, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information. We may use and disclose your protected health information (PHI) only for each of the following purposes: treatment, payment and health care operations. ● Treatment means providing, coordinating, or managing health care and related services by one or more healthcare providers. An example of this would be when we consult with other health care providers. ● Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment. ● Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review. We may also create and distribute de-identified health information by removing all references to individually identifiable information. We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

SPECIAL SITUATIONS We may use or disclose protected health information without your consent or authorization in the following circumstances: ● Child Abuse - If we have reasonable cause to believe that a child has been abused, we must report that belief to the appropriate authority immediately, but no later than 24 hours after the suspicion arises. ● Adult and Domestic Abuse - If we have reasonable cause to believe that a disabled adult or elder person has had a physical injury or injuries inflicted upon such disabled adult or elder person, other than by accidental means, or has been neglected or exploited, we must report that belief to the appropriate authority. ● Health Oversight Activities - If we are the subject of an inquiry by an overseeing Board of Examiners, we may be required to disclose protected health information regarding you in proceedings before the board. ● Judicial and Administrative Proceedings - If you are involved in a court proceeding and a request is made about the professional services we provided you, or the records thereof, such information is privileged under state law, and we will not release information without your written consent or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case. ● Serious Threat to Health or Safety - If we determine, or pursuant to our professional standards should determine, that you present a serious danger of violence to yourself or another, we may disclose information in order to provide protection against such danger for you or the intended victim. ● Workers’ Compensation - We may disclose protected health information regarding you as authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU You have the following rights with respect to your protected health information, which you can exercise by presenting a written request. - The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it. - The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations. - The right to inspect and copy your protected health information. - The right to amend your protected health information. - The right to receive an accounting of disclosures of protected health information. - The right to obtain a paper copy of this notice from us upon request. We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office. You have recourse if you feel that your privacy protections have been violated. You have the right to file a written complaint with our office, or with the Department of Health & Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint. For more information about HIPAA or to file a complaint: The U.S. Department of Health & Human Services, Office of Civil Rights 200 Independence Avenue, S.W. Washington, D.C. 20201 (202) 619-0257 Toll Free: 1-877-696-6775