This notice describes how medical information regarding your health care, including payment for health care, is protected by two federal laws: the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 42 U.S.C. § 1320d et seq., 45 C.F.R. Parts 160 & 164, and the Confidentiality Law, 42 U.S.C. § 290dd-2, 42 C.F.R. Part 2. Under these laws, My Teen Mental Health may not tell a person outside of My Teen Mental Health that you attend the program, nor may My Teen Mental Health disclose information identifying you as a person receiving mental health or substance use services, or disclose any other protected information except as permitted by federal law.

Our Pledge Regarding Health Information

My Teen Mental Health uses health information about you for treatment, to obtain payment for treatment, for administrative purposes, and to evaluate the quality of care that you receive. Your health information is contained in a medical record that is the physical property of My Teen Mental Health.

• We understand that health information about you and your health is personal.
• We are committed to protecting health information about you.
• This notice tells you about the ways in which we may use and disclose health information about you.

We also describe your rights and certain obligations we have regarding the use and disclosure of health information.

My Teen Mental Health Is Required by Law To:

• Make sure that medical information that identifies you is kept private.
• Give you this notice of our legal duties and privacy practices with respect to medical information about you.
• Accommodate reasonable requests you may make to communicate health information by alternative means or at alternative locations.
• Follow the terms of this notice that is currently in effect.

How We May Use and Disclose Your Health Information

For Treatment

My Teen Mental Health may use your health information to provide you with medical treatment and services. For example, a health care provider — such as a physician, nurse, or other person providing health care services to you — will record information in your record that is related to your treatment. This information is necessary for health care providers to determine what treatment you should receive. Health care providers will also record actions taken in the course of your treatment and note how you respond to those actions.

For Payment

My Teen Mental Health may use and disclose your health information to others for the purpose of receiving payment for treatment and services that you receive. For example, a bill may be sent to you or to a third party, such as an insurance company, HMO, or health plan. The information on the bill may contain information that identifies you, your diagnosis, and the treatment or supplies used in the course of treatment.

For Health Care Operations

My Teen Mental Health may use and disclose health care information about you for operational purposes. For example, your health information may be disclosed to members of the medical staff, risk or quality improvement personnel, and others to:

• Evaluate the performance of our staff.
• Assess the quality of care and outcomes in your case and in similar cases.
• Learn how to improve our facilities and services.
• Determine how to continually improve the quality and effectiveness of the health care we provide to our clients.

Appointments / Health-Related Products and Services

My Teen Mental Health may also contact you by phone, email, mail, or other non-SMS communication methods to tell you about treatment alternatives or other health-related benefits and services that may be of interest to you. This promotional communication does not include SMS or text messages. My Teen Mental Health will only send SMS/text messages in accordance with your separate consent to receive such messages, and you may opt out of SMS communications at any time by replying STOP.

SMS / Text Messaging Privacy Disclosure

My Teen Mental Health may offer SMS/text messaging to individuals who provide their mobile phone number and consent to receive text messages from us. By providing your mobile number and opting in to receive SMS communications, you agree that My Teen Mental Health may send you text messages related to your inquiry, admissions process, appointment reminders, care coordination, insurance verification, follow-up communication, and other service-related updates.

Message frequency may vary depending on your interaction with My Teen Mental Health. Message and data rates may apply.

Mobile information and SMS consent will not be shared, sold, rented, or disclosed to third parties or affiliates for marketing or promotional purposes. We may share mobile information with service providers only as necessary to deliver SMS messages on our behalf, support our communications systems, or comply with applicable legal obligations. These service providers are not permitted to use your mobile information for their own marketing or promotional purposes.

You may opt out of receiving SMS messages at any time by replying STOP to any text message you receive from us. After you opt out, you may receive one final confirmation message, and we will no longer send SMS messages to that mobile number unless you opt in again.

For assistance, reply HELP to any SMS message you receive from us, or contact My Teen Mental Health directly at (209) 251-1132 or contact@myteenmentalhealth.com.

Special Situations

Others Involved in Your Care

My Teen Mental Health may release relevant health information to a family member, friend, or anyone else you designate in order for that person to be involved in your care or in payment related to your care. My Teen Mental Health may also disclose health information to those assisting in disaster relief efforts so that others can be notified about your condition, status, and location.

Fundraising

My Teen Mental Health does not use your information for fundraising unless authorized, in writing, by you.

Required by Law

My Teen Mental Health may use and disclose information about you as required by law. For example, My Teen Mental Health may disclose information for the following purposes:

• For judicial and administrative proceedings pursuant to a court order.
• To prevent or control disease, injury, or disability.
• To report births and deaths.
• To report reactions to medications or problems with products.
• To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease, or to notify the proper authorities if we believe a client has been the victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

Public Health

Your health information may be used or disclosed for public health activities such as assisting public health authorities or other legal authorities (State Health Department, Centers for Disease Control, etc.) to prevent or control disease, injury, or disability, or for other public health activities.

Health Oversight Activities

My Teen Mental Health may disclose your health information to a health oversight agency for activities authorized by law. Examples of these activities include audits, investigations, and inspections to monitor the health care system and compliance with laws and regulations.

Decedents

Health information may be disclosed to funeral directors or coroners to enable them to carry out their lawful duties.

Health and Safety

Your health information may be disclosed to avert a serious threat to your health and safety or that of any other person, pursuant to applicable law.

Workers' Compensation

Your health information may be used or disclosed in order to comply with laws and regulations related to Workers' Compensation.

Other Uses

Other uses and disclosures will be made only with your written authorization. You may revoke an authorization except to the extent that My Teen Mental Health has taken action in reliance on it.

Your Health Information Rights

Under HIPAA, you have the right to:

• Obtain a copy of this notice of information practices upon request.
• Request an amendment to your health information under certain circumstances.
• Request confidential communications of your health information by alternative means or at alternative locations. Please note that this request for alternative means or locations of communication applies only to this provider or location.
• Receive an accounting of disclosures made of your health information.
• Request a restriction on certain uses and disclosures of your information; however, My Teen Mental Health is not required to agree to a requested restriction.

Changes to This Notice

My Teen Mental Health reserves the right to change the terms of this notice and to make the new terms effective for all protected health information kept by My Teen Mental Health. The administration will post a copy of the current notice in the facility. You may also obtain a current copy by contacting our Human Resources Department (address at the end of this statement). The effective date of the notice is in the top right-hand corner of each page.

Complaints

If you believe your privacy rights have been violated, you may file a complaint at any time with My Teen Mental Health or with any of the following:

To file a complaint with My Teen Mental Health, submit your written complaint to our Administrator (address below). You will not be penalized for filing a complaint.

Contact Information for Questions or to File a Complaint

If you have any questions about this notice, want to exercise one of the rights described in this notice, or want to file a complaint, please contact My Teen Mental Health at: