Child & Family (C&F) respects the privacy of our clients' personal information. This notice explains how we use and disclose the information we gather about you to provide you services and treatment. We call this information protected health information (PHI). You have the right to the confidentiality of your PHI in accordance with the law and our policies.

We understand that information about you and your mental and physical health is personal and confidential. Therefore, protecting information about you is important to us. We create a record relating to the care and services you receive from us. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all records of your care maintained by Child & Family, whether made by service/treatment professionals or other personnel.

This notice will tell you about the ways in which we may use and disclose PHI about you. It also describes your rights and certain obligations we have regarding the use and disclosure of PHI. We are required by law to:

• maintain the privacy of PHI;
• give you this notice of our legal duties and privacy practices with respect to PHI; and
• follow the terms of the notice that is currently in effect.

How We May Use and Disclose Information about You
Child & Family is permitted to use and disclose your PHI for the purpose of treatment, payment and healthcare operations once you have given your written consent. When required, we will obtain your written authorization before disclosing any of your information.

For Treatment:
We will use and disclose your PHI to those treatment providers involved in your care. Different departments of our agency also may share your PHI in order to coordinate the different things you need, such as prescriptions or lab work. We may also disclose this information to other healthcare providers that you see outside Child & Family to maintain your continuity of care.

For Payment:
Your PHI will be used, as needed, to submit bills for payment and to obtain payment from you, your insurance company or a third-party payer, as well as to obtain authorization for services.

For Healthcare Operations:
We may use and disclose PHI about you in the course of operating Child & Family. For example, we may use PHI about you for quality improvement, to review our treatment services and to evaluate the performance of our staff. We may also disclose information about you to personnel for review and training purposes.

Disclosures of PHI that may occur WITHOUT Your Written Authorization:

• For emergency treatment, when written authorization is not feasible, but implied;
• To government or law enforcement agencies in response to, but not limited to, court orders, subpoenas, or criminal conduct involving our organization;
• For reports required by law, such as victims of abuse, mistreatment, or neglect; problems with medical and other products, and reactions to medications; and certain types of injuries;
• To a correctional institution, if you are an inmate;
• For health system oversight activities, such as audits, investigations, inspections, licensure and accreditation;
• For Worker's Compensation;
• To avert a serious threat to health or safety, consistent with state law, when it is necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, will only be to someone who is able to help prevent the threat;
• To a Medical Examiner, to identify a deceased person or determine cause of death;

Your Rights Regarding Your PHI:
Right to Review and Receive a Copy - You have the right to review and receive a copy of PHI that may be used to make decisions about your care. You must submit your request in writing to the Agency's Privacy Officer at the address on the last page of this document. If you request a copy of PHI, we may charge a fee for the costs of copying, mailing and other supplies associated with your request. In certain situations, we may deny your request to read and copy your PHI. You have the right to have this decision reviewed and the decision to deny access may be reversed.

Right to Amend - If you feel that any PHI we have about you is incorrect or incomplete, you may ask us to fix the information. You have the right to request a correction for as long as the information in maintained by Child & Family. Your request for a correction must be submitted in writing and include a reason for the request. You should submit your request to the address listed below. We may deny your request for a variety of reasons. If we deny your request, we will inform you in writing of the reason(s) for the denial and explain your rights regarding appealing the denial.

Right to an Accounting of Disclosures - You have a right to request a list of disclosures of your PHI made after April 13, 2003. We are not required to maintain this list for disclosures made for treatment, payment or healthcare operations. To obtain a list of disclosures, you must submit a written request to the address list below.

Right to Request Restrictions - You have the right to request a restriction or limitation on the PHI we use or disclose about you. If we agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must submit your request in writing to the address listed below. 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 limit to apply.

Right to Request Confidential Communications - You have the right to request that we communicate with you regarding your PHI in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. We will comply with your request so long as we can easily provide the information in the way you request.

Right to a Paper Copy of this Notice - You have a right to a paper 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 also obtain a copy of this notice at our website: www.childandfamilyri.com

Changes to this Notice:
We reserve the right to change this notice at any time. Any change we make will apply to PHI we already have as well as any information we receive in the future. We will post a copy of the current notice in the Child & Family reception area. This notice supersedes any and all prior versions of this notice.

Person to Contact for Information about this Notice or to File a Complaint about our Privacy Practices
If you have any questions about this notice, wish to exercise any of the rights explained in it, wish to file a complaint about our privacy practices, feel that we may have violated your privacy rights, or disagree with a decision made about your PHI, please contact our Privacy Officer at the address listed below.

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. We will not retaliate against you for filing a complaint.

Vice President of Organizational Quality & Performance
Child & Family
31 John Clarke Road
Middletown, RI 02842
(401) 848-4186

I have received Child & Family's Notice of Privacy Practices.

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Signature of Client (not required if client is a minor)         Date

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Signature of Caregiver (if client is a minor)                       Date

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C&F Representative                                                         Date

This page (3 of 3) is carbon copied. One copy is for the client (white) and one copy is for the record (yellow).