Privacy Policy

This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. "Protected health information" is information about you, including genetic information & demographic information, whether oral or recorded in any form or medium, that is created or received by a healthcare provider, health plan, public health authority, employer, life insurer, school or university or healthcare clearinghouse and relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual.

We are required to abide by the terms of this Notice of Privacy Practices.

We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices by accessing our website www.proactiveminds.net or calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.

Uses and Disclosures of Protected Health Information Based Upon Your Written Consent. Following are examples of the types of uses and disclosures of your protected health care information that the practice is permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office.

We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party provider. For example, we would disclose protected health information to another physician or health care provider (e.g., a specialist or laboratory) who, at the request of your provider, becomes involved in your care.

Your protected health information will be used, as needed, to obtain payment for your health care services. This may include providing health information for making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities.

For example, we may use your protected health information to assess the quality of care at Proactive Minds. We may use or disclose your protected health information, as necessary, for appointment reminders or to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. You may contact our Privacy Office to request that these materials not be sent to you.

We will share your protected health information with third party "business associates" that perform various activities (e.g., billing, transcription services) for the practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.

Uses and Disclosures of Protected Health Information Based upon Your Written Authorization. Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law. You may revoke this authorization, at any time, in writing, except to the extent that your provider or the practice has taken an action in reliance on the use or disclosure indicated in the authorization.

Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person's involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.

We may use or disclose your protected health information in an emergency treatment situation. If this happens, your provider shall try to obtain your consent as soon as reasonably practicable after the delivery of treatment. If your provider or another provider in the practice is required by law to treat you and the provider has attempted to obtain your consent but is unable to obtain your consent, he or she may still use or disclose your protected health information to treat you.

We may use and disclose your protected health information if your provider or another provider in the practice attempts to obtain consent from you but is unable to do so due to substantial communication barriers and the provider determines, using professional judgment, that you intend to consent to use or disclosure under the circumstances.

The following uses and disclosures will be made only with authorization from the patient/representative: (1) for use and disclosures for marketing purposes; (2) for use and disclosures that constitute the sale of PHI; (3) most uses and disclosures of psychotherapy notes (if maintained) and, (4) other uses and disclosures as required by law.

We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures.

We may disclose your protected health information to the CDC and other public health authorities for public health activities as permitted by law. The disclosure will be made for the purpose of controlling disease, injury or disability.

We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

We may disclose protected health information to the US Department of Health and Human Services, or other health oversight agency for activities authorized by law, such as audits, investigations, and inspections.

We may disclose your protected health information to Child Protective Services, Adult Protective Services, or other governmental body that is authorized by law to receive reports of abuse or neglect. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.

We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.

We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.

We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to witnesses, defendants, or victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of the practice, and (6) medical emergency and it is likely that a crime has occurred.

We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.

Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.

When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.

Your protected health information may be disclosed by us as authorized to comply with workers' compensation laws and other similar legally-established programs. Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of federal law.

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 inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you that is contained in a designated record set for as long as we maintain the protected health information. A "designated record set" contains medical and billing records and any other records that your provider and the practice use for making decisions about you. We will provide information in paper or electronic form based on your preference if we have the ability to do so.

You have the right to request a restriction of your protected health information to your health plan when that information relates solely to a healthcare item or service for which you, or another person on your behalf (other than a health plan), has paid us in full. Proactive Minds may release restricted protected healthcare information as "required by law". 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 of Privacy Practices.

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. We may also condition this 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. Please make this request in writing to our Privacy Office.

You may have the right to have your provider 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. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices. The right to receive this information is subject to certain exceptions, restrictions and limitations.

You have a right to or will be notified of a breach of unsecured protected healthcare information. If a breach of your medical information occurs and if that information is unsecured (not encrypted), we will notify you with a brief description of what happened, a description of the health information that was involved, recommended steps you can take to protect yourself from harm and what steps we are taking in response to the breach and contact procedures so you can obtain further information.

You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.

You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. We will not retaliate against you for filing a complaint. To file a written complaint with us, you may bring your complaint directly to our Privacy Office or you may contact us at:

Proactive Minds — Privacy Office

Website: www.proactiveminds.net Email: support@proactiveminds.net Phone: +1 (303) 226-7171

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.

If you have any questions about this Notice please contact our Privacy Office at support@proactiveminds.net or

+1 (303) 226-7171. Notice published & becomes effective July 1, 2013.

I hereby give consent for Proactive Minds and their business associates (such as but not limited to the medical billing company, EHR vendor, collection agency, automated appointment reminder vendor, dictation service, and electronic prescription vendor) to use and disclose protected health information about me to carry out treatment, payment, and health care operations. You can ask for a copy of the Notice of Privacy Practices provided by Proactive Minds, which describes such uses and disclosure in detail.

I have the right to review the Notice of Privacy Practices prior to signing this consent. Proactive Minds reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to the privacy officer at Proactive Minds or by visiting www.proactiveminds.net.

With this consent, Proactive Minds may communicate to me in reference to any items that assist the practice in carrying out TPO, such as, but not limited to appointment reminders, billing statements, insurance issues and any message pertaining to my clinical care including lab results, among others by use of phone calls to my home, mobile or other alternative location and speak or leave a message, text message, email, postal delivery and or by Patient Portal. By signing this form, I am consenting to allow Proactive Minds to use and disclose my PHI to carry out TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Proactive Minds may decline to provide treatment to me.

Proactive Minds is committed to protecting the privacy of our users. We outline how we collect, use, disclose, and safeguard your personal information when you visit our website or use our services.

We may collect personal information from you when you interact with our website or use our services. This information may include, but is not limited to:

• Name

• Email address

• Phone number

• Mailing address

We may use the information we collect from you for various purposes, including:

• To provide and maintain our services • To improve our services and develop new features • To communicate with you, including responding to inquiries and providing customer support • To send you marketing and promotional communications, if you have opted in to receive them

• To comply with legal obligations

By providing your phone number, you consent to receive SMS messages from us regarding the purpose of your inquiry. Please note that standard message and data rates may apply.

We take reasonable measures to protect your personal information from unauthorized access, use, or disclosure. However, no method of transmission over the internet or electronic storage is 100% secure, and we cannot guarantee absolute security.

We do not sell, trade, or otherwise transfer your personal information to third parties for marketing purposes. We may share your information with trusted third parties who assist us in operating our website or providing our services, as long as those parties agree to keep this information confidential.

You have the right to access, correct, or delete your personal information. You may also choose to opt-out of receiving marketing communications from us at any time.

We reserve the right to update or change our Privacy Policy at any time. Any changes will be effective immediately upon posting the revised Privacy Policy on our website at www.proactiveminds.net.