Welcome to New Horizons Healthcare

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1 MEDICATION ASSISTANCE PROGRAM DRUG BENEFITS POLICY Welcme t New Hrizns Healthcare New Patient Infrmatin Packet Please read the entire packet, cmplete the applicatins, and bring all necessary dcumentatin t yur appintment with ur Eligibility Crdinatr. Yur appintment will be rescheduled with the Eligibility Crdinatr if packet is incmplete r requested dcumentatin is nt available.

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3 3716 Melrse Avenue NW Ranke, VA (540) Check us ut at: facebk.cm/newhriznshealthcare Welcme t New Hrizns Healthcare! Please read the entire packet, cmplete the applicatins, and bring all necessary dcumentatin t yur appintment with ur Eligibility Crdinatr r yur appintment will be rescheduled. ALL APPOINTMENTS Because f the demand fr ur services, it is very imprtant t keep yur scheduled appintment. If unfreseen circumstances require yu t cancel r reschedule, please give us at least a 24 hurs ntice by calling ur ffice at (540) Yur curtesy will allw us t schedule anther patient. Ntificatin less than 24 hurs is cnsidered a n shw. Mre than three n-shw appintments in a 12 mnth perid will jepardize yur ability t make future scheduled appintments and we wuld like t avid that situatin. INITIAL APPOINTMENT WITH ELIGIBILITY COORDINATOR THE FOLLOWING INFORMATION IS REQUIRED FOR ALL PATIENTS: Yur driver s license r ther pht ID. We need t make a cpy f yur license fr ur file. Yur cmpleted Patient Health Histry Frm Yur cmpleted Sliding Fee Discunt Applicatin with requested dcumentatin (See infrmatin regarding this prgram belw) Yur insurance card if yu have insurance. If yu are cvered by insurance, cmplete the Insurance Declaratin Page. SLIDING FEE DISCOUNT PROGRAM AVAILABLE FOR MEDICAL OFFICE CHARGES AND FOR MEDICATION ASSISTANCE PROGRAM (MAP) All patients may apply (insured and uninsured) fr the Sliding Fee Discunt Prgram. If yu have insurance, yu may qualify fr additinal discunts n charges under ur Sliding Fee Prgram based n yur annual incme and the size f yur family. This discunt may be applied t yur deductible r c-insurance. If yu have insurance, but d nt have cverage fr drugs, yu may als qualify fr help with yur medicatins thrugh the MAP. The sliding fee discunt is gd fr ne year and yu will need t reapply annually. An applicatin t apply fr this prgram is enclsed. Eligibility cannt be determined until we receive all requested infrmatin frm yu. If it is determined yu are nt eligible fr a sliding fee and yu have incurred charges, yu will be expected t pay the balance due. ESTABLISHING ELIGIBILITY IS REQUIRED BY BRINGING APPLICATION AND ALL DOCUMENTATION BELOW: Wages frm emplyment (30 days) Cpy f yur MOST RECENT Federal Incme Tax Return r a cmpleted Federal Frm 4506T (Verificatin f Nn-Filing). Our ffice will prvide this frm, if needed. Check stubs r statements shwing INCOME frm Scial Security; Disability; Retirement r Veteran s Benefits; Temprary Assistance t Needy Families; Rental Assistance; Child Supprt and/r Rental Incme. If yu d nt have an incme frm any f the surces abve, please cmplete the enclsed Husing and Supprt Verificatin Frm t help us verify yur current living circumstances t establish eligibility. If yu have questins abut yur Sliding Fee Guidelines r the Pharmacy Assistance Prgram, yu may call ur Eligibility Crdinatr at MEDICAL RECORDS FROM ANOTHER PHYSICIAN A frm fr yu t sign t allw us t request yur medical recrds frm anther dctr r clinic if needed will be prvided at yur eligibility appintment. I acknwledge by my signature belw, that I have read and agree with the prvisins f the Sliding Fee Prgram. I acknwledge and understand that I will be cnsidered respnsible fr all charges until the Sliding Fee Determinatin is cmplete and I am deemed eligible. If I am nt eligible, I understand I will be respnsible fr all charges. Applicant r Respnsible Party s Signature Thank yu fr chsing New Hrizns Healthcare fr yur healthcare needs. Date

4 3716 Melrse Avenue NW Ranke, VA (540) Check us ut at: facebk.cm/newhriznshealthcare Instructins fr Sliding Scale Applicatin 1. Fill in every blank field. If fields are left blank, yur applicatin will be cnsidered incmplete. It will be returned t yu. 2. Fill ut incme infrmatin. If any individual in the husehld is ver 18 and is cnsidered a dependent (i.e. full time student r disabled), prf f dependence is required. Independent individuals ver 18 in the husehld must apply separately. The fllwing types f dcumentatin are required, as applicable, t dcument yur incme: EMPLOYED: If emplyed during ttal f previus tax year, then the prir year s IRS 1040 Incme Tax Return OR One mnth s wrth f CURRENT pay stubs shwing grss incme OR A letter frm yur emplyer stating ne (1) mnth grss salary SELF EMPLOYED: Prir year s Federal Incme Tax return (IRS 1040), alng with Schedule C. UNEMPLOYED NO INCOME: Letter frm family r a friend cnfirming yur need f Financial Assistance, r a Ntarized Letter verifying yur lack f incme. UNEMPLOYMENT/WORKER S COMPENSATION: Frms verifying weekly benefit amunt r Denial f benefits SICK LEAVE: Statement frm yur dctr stating dates yu are unable t wrk Statement frm emplyer indicating paid sick leave If yu are n leave withut pay, letter frm emplyer prviding yur year-t-date grss incme and yur hire date. GOVERNMENT BENEFITS: Scial Security, SSI, VA, Disability, r ther gvernment benefits Letter cnfirming r denying, OR Phtcpy f check(s), OR Bank statement shwing autmatic depsit The Current Benefit Statement may be btained frm Scial Security by calling SOCIAL SERVICES: Ntice f Actin : Fd Stamps, General Relief, Aid t Dependent Children, TANF Letter cnfirming receipt f husing OTHER RESOURCES: Prvide legal prf, bank statement, r fficial award letter Retirement benefits Trust fund alltments Child Supprt and/r Alimny received (nt paid). HOMELESS: If hmeless, a letter frm current shelter is required. LIQUID ASSETS: Prvide statement(s) frm Bank r Credit Unin Savings Investments CD S Interest, Dividends OTHER: Cpy f custdy papers fr ther dependents in yur hme. 3. Hw did yu hear abut us? 4. Medicare D yu have Medicare Part-D prescriptin drug cverage: Yes /N Did yu qualify fr extra help t assist with the cst f yur premium and c-pays: Yes / N Wuld yu like additinal inf abut Medicare Part D prescriptin drug cverage: Yes / N Cmments: use this area t explain any unusual circumstances which yu feel may be helpful.

5 3716 Melrse Avenue NW Ranke, VA (540) Check us ut at: facebk.cm/newhriznshealthcare APPLICATION FOR FINANCIAL ASSISTANCE SLIDING SCALE PROGRAM APPLICANT S INFORMATION PERSONAL INFORMATION STATISTICS First Name: Are yu a United States Veteran? Yes / N Last Name: D yu need an interpreter? Yes / N Date f Birth: Gender: M / F Which language d yu speak? Mailing Address: City, ST, Zip: Hw many are in yur family? (The IRS defines a family as yurself, yur spuse & any dependents) Marital Status: Cunty: Race: Ethnicity: Hme Telephne Number: African-American Native American Hispanic Cell Telephne Number: Asian Pacific Islander Nn-Hispanic Wrk Telephne Number: Caucasian Mre than ne List f family members: ( include yurself) FAMILY MEMBER S INFORMATION Scial Security #: Date f birth: Relatin: Mnthly Grss Incme* Emplyer name: (if emplyed) New Renewal Full-time Student? * If smene can claim yu as a dependent, then list all ther family members. DOCUMENT & PROVIDE PROOF OF ALL INCOME RECEIVED Emplyment, Retirement, Scial Security, Pensin, V.A., Disability, Wrker s Cmpensatin, Unemplyment, Child Supprt, and All thers nt listed. Applicatin will be rejected due t failure t cmply! EMPLOYMENT INFORMATION EMPLOYER INFORMATION Date Emplyment Began: Emplyer Phne Number: Hw ften are yu paid? Amunt yu are paid: INCOME INFORMATION UNEMPLOYMENT INFORMATION DISABILITY INFORMATION If unemplyed, date emplyment ended: If unemplyed, has anyne applied fr Disability? Yes / N Des anyne receive unemplyment wages? Yes / N Is anyne in yur family* planning n applying fr Disability? Yes / N If s, prvide amunt received: *This includes yu. MISCELLANEOUS INFORMATION GOVERNMENT ASSISTANCE INFORMATION PERSONAL INFORMATION Medicaid? Yes / N Wh? Child Supprt Received (nt paid): Yes / N Amunt: $ Fd Stamps? Yes / N Amunt: $ Alimny Received (nt paid): Yes / N Amunt: $ D yu/spuse r any f yur children under the age f 18 receive Checking Accunt: Yes / N Amunt: $ Scial Security Benefits: Yes / N Saving Accunt: Yes / N Amunt: $ FEDERAL TAX RETURN INFORMATION D yu Receive rental incme? Yes / N Amunt: $ Stcks, Bnds, CD s, Did yu file incme taxes fr last year: Yes / N IRA s: Yes / N Was yur filing: Jint r Single BEHAVIORAL HEALTH SERVICES INSURANCE INFORMATION D yu receive services frm ne f the fllwing facilities? D yu r thers in the family have insurance? Yes / N Blue Ridge Behaviral Health Name(s): East Mental Health Insurance? (please bring card) Private Mental Health Physician DECLARATION: The infrmatin prvided abve is, t the best f my knwledge and belief, cmplete, accurate and true. I authrize the release f all infrmatin which New Hrizns Healthcare may need t determine whether I qualify fr financial assistance thrugh the Sliding Scale Prgram. Applicant s Signature: Date Spuse s Signature: Date Office Use Only (belw this line)

6 4910 Valley View Blvd NW, Suite 310 Ranke, VA (540) NHH: Incme: S/S Status: Eff. Dates: Check us ut at: facebk.cm/newhriznshealthcare Seasnal Y / N (Circle) Migrant? Y / N (Circle) Date/Init.: INSURANCE DECLARATION PAGE Please present ALL insurance cards t Eligibility Crdinatr at time f appintment. NO INSURANCE COVERAGE I currently d nt have any medical insurance r pharmacy prescriptin cverage, whether thrugh the gvernment (Medicare r Medicaid), emplyment, r a private cmpany. When I receive insurance cverage r pharmacy prescriptin cverage, I will ntify New Hrizns Healthcare within 30 days f the start date f the new insurance and will prvide a cpy f my card. Initial here: Cmpany name: Address: City, St, Zip: INSURANCE COMPANY INFORMATION Subscriber/Plicy/Medicaid/Medicare #: Grup #: Cmpany name: Address: City, St, Zip: PRIMARY INSURANCE COVERAGE Plicy Hlders Name: Plicy Hlders DOB: SUBSCRIBER INFORMATION Plicy Hlders Emplyer: Relatinship t the patient: Des yur primary insurance ffer prescriptin drug cverage? Y / N INSURANCE COMPANY INFORMATION Subscriber/Plicy/Medicaid/Medicare #: Grup #: SECONDARY INSURANCE COVERAGE Plicy Hlders Name: Plicy Hlders DOB: SUBSCRIBER INFORMATION Plicy Hlders Emplyer: Relatinship t the patient: Des yur secndary insurance ffer prescriptin drug cverage? Y / N Pharmacy name: Address: City, St, Zip: Phne #: PREFERRED PHARMACY INFORMATION DECLARATION By signing belw I am acknwledging that the abve infrmatin it true and accurate t the best f my knwledge. I als attest that if it is fund that I am knwingly withhlding insurance infrmatin and the time frame t file previus claims has been exceed I will be held respnsible fr any past due amunts. Applicant s Signature Date Witness Signature Date

7 MEDICATION ASSISTANCE PROGRAM DRUG BENEFITS POLICY New Hrizns Healthcare emplys a Medicatin Assistance Prgram (MAP) team t rganize applicatins fr free medicatins fr thse wh qualify fr indigent prgrams ffered by pharmaceutical cmpanies. By signing belw, yu are agreeing t abide by the fllwing terms: Yu must have a medical appintment with yur New Hrizns Healthcare (NHH) Primary Care Prvider every three mnths unless therwise instructed by yur Primary Care Prvider. Yu will btain lab wrk pertinent t the medical management f yur diagnsis as instructed by yur NHH Primary Care Prvider. If yu d nt cmply with yur medical management plan as instructed by ur staff, yur participatin will be terminated with this prgram. It will be yur respnsibility t give ntice t ur MAP staff in a timely manner that yu need mre medicatin t be rdered thrugh the MAP spnsred by the varius drug manufacturers. Yu must call the MAP staff t rerder additinal medicatin after yu have cmpleted a ne-mnth supply f medicatin. Failure t give enugh ntice t prvide an uninterrupted supply may result in yu having t pay fr yur prescriptin at the regular retail pharmacy price until medicatins may be btained frm the manufacturer. Sliding fee discunts will nt be applied tward a medicatin that culd therwise be btained thrugh this prgram. Yu must ntify the MAP staff immediately in the event f any changes regarding yur husehld, such as change f address, husehld status (e.g. marriage, divrce, birth, adptin), change f incme, new insurance, Medicare, r Medicaid cverage, etc. Yu must ntify the MAP staff in the event that yur prvider discntinues any f yur medicatins, changes a dse r the number f times that yu take yur medicatin each day immediately. Failure t prvide ntificatin f a medicatin change may result in an interruptin f yur medicatin. Yu must cmplete the annual re-enrllment prcess and prvide specific incme dcumentatin upn request. Failure t cmply with this request will terminate yur participatin in this prgram. It is yur respnsibility t pick up yur medicatins nce yu are ntified. Yu will receive a letter stating medicatin(s) is available fr pick up. All medicatins must be picked up within 30 days after being ntified by ur ffice. Please cntact ur ffice immediately t request an extensin f time. If yu fail t pick up within 30 days, yur medicatins will be returned t the drug manufacturer. It will be yur respnsibility t replace medicatins that are lst r stlen after yu have signed fr them. New Hrizns Healthcare cannt guarantee the prvisin f medicatins btained thrugh MAP spnsred by varius drug manufacturers. Yu have the ptin f purchasing the medicatins at the retail pharmacy f yur chice. New Hrizns Healthcare may btain sme medicatins n yur behalf thrugh varius medicatin assistance prgrams, utside f New Hrizns Healthcare. Each medicatin is charged a $10.00 fee and is due at time f pick-up. The fee is nt t cver the medicatin, but the administrative csts assciated with prcessing applicatins fr medicatins received thrugh this prgram. N refunds are given fr medicatin btained thrugh ur prgram. I hereby authrize New Hrizns Healthcare s MAP staff as designated Patient Assistance Advcates t sign my name n the necessary pharmaceutical frm(s) that may be required fr rdering my needed medicatins. I, the undersigned, certify that I have read and agree t the Plicy fr New Hrizns Healthcare s MAP benefits. I understand that vilatin f any part f the plicy may make me ineligible fr future MAP services. Applicant s Signature: Date:

8 4910 Valley View Blvd NW, Suite 310 Ranke, VA (540) Check us ut at: facebk.cm/newhriznshealthcare HOUSING AND SUPPORT VERIFICATION FORM T determine eligibility fr discunted services, please cmplete ONE f the fllwing that apply t yur situatin as f the date f this frm. We appreciate yur cperatin and wish t assure yu that any infrmatin prvided will be cnsidered cnfidential. Check All That Apply: PATIENT STATEMENT I d nt receive any frm f public assistance fr husing r living expenses I d nt have anyne t vuch fr my living arrangements Other - Explain: Initial Here ARE YOU HOMELESS OR LIVE IN A SAFETY SHELTER? (RAM, TRUST, SALVATION ARMY, ETC.) If yes, please have a representative f the shelter fill ut this sectin and sign. Thank yu. T New Hrizns Healthcare: has been a resident at (Applicant s Name) (Facility Name) frm t (Date) (Date) (Phne Number fr Verificatin) (Signature) (Title) (Date) DO YOU RECEIVE SUBSIDIZED HOUSING? If yes, please have a representative f the Husing Authrity fill ut this sectin and sign. Thank yu. T New Hrizns Healthcare: is a current resident f (Applicant s Name) (Address) All rental fees are subsidized by (Lcality Name) (Phne Number) (Signature) (Title) (Date) IS YOUR FOOD AND SHELTER PROVIDED BY FRIENDS/FAMILY OR MEMBER/ORGANIZATION? If yes, please have this sectin filled ut and signed by the persn prviding assistance. Thank yu. T New Hrizns Healthcare: I am prviding with fd and shelter. (Print Name) (Applicant s Name) This individual has n ther means f supprt t the best f my knwledge. I am prviding this supprt until. (Signature) (Date) Address Phne AUTHORIZATION TO RELEASE INFORMATION I authrize any abve named rganizatin r persn t release infrmatin fr verificatin f husing and supprt (living expenses) as requested. Patient r Respnsible Party Signature: Date:

9 Last Name: First Name: Birth Date: CURRENT MEDICATIONS (INCLUDE NON-PRESCRIPTION PRODUCTS) MEDICATION/STRENGTH DOSAGE MEDICATION/STRENGTH DOSAGE LIST ALL MEDICATION ALLERGIES: Aspirin? Yes / N If yes, circle ne: 81mg r 325mg MEDICAL ILLNESSES OR CONDITIONS CONDITION ONSET DATE CONDITION ONSET DATE CONDITION ONSET DATE Acid Reflux Emphysema/COPD Neck/Back Prblems Anxiety Erectile Dysfunctin Paralysis Arthritis Fractures Psriasis Asthma Glaucma Seizures Cancer Heart Attack STD s Cataracts Heart Catheterizatin Strke Depressin Heart Murmur Thyrid Disrder Diabetes/Sugar High Bld Pressure Tuberculsis Diabetic Neurpathy High Chlesterl Ulcer Disease Diverticulsis HIV Urinary Tract Infectins DVT/Cltting Disrder Kidney Stnes Other Eczema Liver Disease Other SURGICAL HISTORY SURGERY YEAR SURGERY YEAR SURGERY YEAR Appendectmy Gall Bladder Remval Jint Replacement Back Surgery Hernia Repair Majr Car Accident Crnary Artery Bypass Hysterectmy Tnsillectmy Tubal Ligatin C-Sectin Other LIST ANY HOSPITALIZATIONS LAST 10 YEARS BELOW: (DATE, HOSPITAL NAME, AND REASON) FAMILY MEDICAL HISTORY: (BLOOD RELATIVES) CONDITION FATHER MOTHER BROTHERS: # SISTERS: # SONS: # DAUGHTERS: # ALIVE / DECEASED ALIVE / DECEASED HEALTHY: Y / N HEALTHY: Y / N HEALTHY: Y / N HEALTHY: Y / N If deceased, give age: Asthma Bleeding Disrders COPD Depressin Diabetes/Sugar Drug r Alchl Abuse Heart Attack High Bld Pressure High Chlesterl Seizures Strkes Family Histry f Cancer - List relatin, type, & age SOCIAL HISTORY TOBACCO USAGE ALCOHOL USAGE EXERCISE D yu smke? D yu drink alchl? D yu regularly exercise? # packs per day Enter # f drinks per day belw: If yes, describe belw:

10 Hw many years? Beer Wine Liqur MISCELLANEOUS Wrking smke detectr in yur hme? D yu drink beverages with caffeine? Are yu sexually active? D yu use drugs ther than yur prescribed medicatins? D yu travel utside the US? Pets? D yu practice a particular religin? If s, what denminatin? Educatin Level: What type f wrk d yu r did yu d? Are yu retired? Are yu disabled? If yes, describe yur disability: GYNECOLOGY HISTORY (FEMALES ONLY) PAP SMEAR MAMMOGRAM Date f last PAP Smear: Date f last Mammgram: Lcatin f last PAP Smear: Lcatin f last Mammgram: Histry f Abnrmal PAP Smear results: Yes / N D yu cnduct Mnthly breast exams? Yes / N Age began menstruating: Date f last menstrual perid: MENSTRUAL CYCLE Hw lng are yur perids? Are they irregular? OB HISTORY (FEMALES ONLY) PREGNANCY #1 #2 #3 #4 #5 #6 #7 #8 #9 #10 Number f Living Children Full-term Delivery Natural r Cesarean N / C N / C N / C N / C N / C N / C N / C N / C N / C N / C Gestatinal Diabetes? Birth Weight ver 9 lbs? Miscarriage/Stillbrn/Abrtin M/ S /A M/ S /A M/ S /A M/ S /A M/ S /A M/ S /A M/ S /A M/ S /A M/ S /A M/ S /A VACCINES / DIAGNOSTIC TESTS VACCINES DIAGNOSTIC TESTS Flu Sht Date: Cardi Stress Test Date: Clnscpy Date: Tetanus/TDAP Date: EKG Date: EGD Upper Endscpy Date: MEN ONLY: PSA Testing: Yes / N Prstate Exam: Yes / N Date: MISCELLANEOUS INFORMATION PATIENT S SIGNATURE: Date: NEW HORIZONS HEALTHCARE 3716 Melrse Ave NW Ranke, VA Patient Name Scial Security # DOB:

11 Sign yur initials next t each sectin: CONSENT FOR TREATMENT: I authrize the emplyees, agents and staff f New Hrizns Healthcare t perfrm and hereby cnsent t such medical treatment and examinatins, including diagnstic prcedures r behaviral health evaluatins and treatment, as may in the pinin f the patient s physician be necessary. NO GUARNATEE: I am aware that the practice f medicine is nt an exact science and I acknwledge that n guarantees have been made as t the result f any prcedures, treatments r examinatins. FINANCIAL RESPONSIBILITY: I understand that I am financially respnsible fr all charges, whether r nt paid by insurance. New Hrizns Healthcare des nt participate in every insurance plan. I understand that I am respnsible fr verifying that my NHH prvider is a participating prvider in my insurance plan. Payment is expected at time f service. RELEASE OF INFORMATION: I authrize the clinic t release my and all f my patient medical and billing infrmatin t any physician invlved in my treatment; t any health care facility t which I/ the patient is discharged r transferred fr treatment, billing, quality assurance, cllectin, r defense f litigatin r anticipated litigatin; and t any insurance cmpany, review rganizatin r ther entity, which is directly r indirectly respnsible fr payment r review f services prvided by New Hrizns Healthcare. I cnsent t use and disclsure f my prtected health infrmatin t carry ut treatment, payment r health care peratins by New Hrizns Healthcare. DEEMED CONSENT FOR BLOOD TESTING: I understand that under Virginia Law, if a health care prvider, a persn emplyed by, under the directin f, r cntrl f a healthcare prvider, Is directly expsed t bdily fluids f a patient, which may transmit viruses causing HIV r Hepatitis B r C, the patients will be deemed t have cnsented t testing fr HIV r Hepatitis B r C, and the release f such test results t the persn wh was expsed. (Expsure culd ccur due t an accidental needle stick.) A patient wh tests psitive will be affrded the pprtunity fr individual face-t-face disclsure f test results and apprpriate cunseling. SLIDING FEE SCALE: Qualifying fr ur sliding fee scale based n yur family incme and family size may result in lwer charges. Yu are required t reprt any incme and family size changes t us as this may impact the amunt yu are expected t pay. We will review and update yur infrmatin annually. Eligibility cannt be determined until we receive all requested infrmatin frm yu. If it is determined yu are nt eligible fr a sliding fee and yu have incurred charges, yu will be expected t pay the balance due. We will assist yu by arranging a payment plan if needed. Yu will be asked t pay a minimum fee fr yu first visit until the sliding fee eligibility prcess is cmplete. The remaining cst f the first and subsequent visits will be based n the utcme f the determinatin. If yu d nt pay fr the services at the time they are rendered, yur balance must be paid in full within sixty (60) days. MEDICARE LIFE-TIME/MEDICAID SIGNATURE AUTHORIZATION AND ASSIGNMENT: I request that payment f authrized Medicare/Medicaid benefits be made n my/the patients behalf fr any services furnished by r in the clinic; including physician services. I authrize any hlder f medical r ther infrmatin abut me, t release t New Hrizns Healthcare fr Medicare and Medicaid Services, the Virginia Department f Medical Assistance Services and their agents, any infrmatin needed t determine these benefits r benefits fr related services. I assign the benefits payable fr physician and ther medical services t the physician r rganizatin furnishing the services and authrize such physician r rganizatin t submit claim t Medicare and/r Medicaid fr payment. I understand that I/the patient am respnsible fr any deductibles, c-payments and any applicable percentage f remaining charges. CERTIFCATION AND ACKNOWLEDGMENT: I certify that all freging infrmatin and all infrmatin supplied by me, as part f the registratin prcess is crrect. I als acknwledge receipt f New Hrizns Healthcare s Ntice f Privacy Practices (HIPAA). Patient r Parent/Legal Guardian Date

12 Yu have the RIGHT NEW HORIZONS HEALTHCARE PATIENT RIGHTS & RESPONSIBILITES T chse New Hrizns Healthcare as yur family health care hme; T be treated with respect and dignity; T expect quality care which takes int cnsideratin yur persnal, spiritual, and cultural values; T receive cnfidential treatment; T access any infrmatin cntained in yur medical recrds; T expect that ur health care prviders and staff will listen t yur needs; T receive helpful and understandable infrmatin abut yur diagnsis, treatment, and prgnsis; T give infrmed cnsent befre the start f a prcedure r treatment; T refuse treatment t the extent allwed by law and t be infrmed f the medical cnsequences; T expect an appintment within a reasnable time frame; T knw the csts f all prcedures r services; T receive and understand the statement f fees fr services prvided. Yu have the RESPONSIBILITY T keep yur appintments r ntify the Center t prmptly cancel s that thers may be seen in yur place; T tell the health care prvider accurate and cmplete infrmatin cncerning yur present cmplaints/symptms, past illnesses / ailments, medicatins, and any ther matters relating t yur health; Fr fllwing the treatment plan recmmended by yur health care prvider; T tell the prvider if yu d nt understand the treatment plan and what is expected f yu; T ntify the Center f any changes in yur persnal infrmatin (address, phne numbers, insurance, emplyment, etc.); T pay fr services prvided r t make arrangements t pay (nly if apprved by management); The patient is respnsible fr being cnsiderate f the rights f ther patients and facility persnnel, which includes refraining frm use f ful language and abusive, threatening, r disruptive behavir; T be respectful f ther patients and staff, and maintain a safe, clean, and cmfrtable ffice envirnment at all times; T infrm staff f any legal-medical infrmatin, such as Pwers f Attrney, that might impact decisins abut yur health care. I, the patient, have read and understand the abve patient rights and respnsibilities: Signature: Date:

13 NEW HORIZONS HEALTHCARE NOTICE OF PRIVACY PRACTICES Effective Date: Nvember 1, 2013 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. This Ntice is being prvided t yu as a requirement f the Health Insurance Prtability and Accuntability Act f 1996 ( HIPAA ). It describes hw, when and why we may use and/r disclse prtected health infrmatin ( PHI ) abut yu. It als describes yur rights t access and cntrl f yur PHI. PHI means any recrded r ral infrmatin abut yu, including demgraphic data, that may identify yu r that can be used t identify yu, that is created r received by New Hrizns Healthcare ( the Cmpany ) and that relates t yur past, present r future physical r mental health r cnditin, the prvisin f health care t yu, r the past, present r future payment fr the prvisin f health care t yu. OUR PLEDGE REGARDING MEDICAL INFORMATION: We understand that PHI abut yu is persnal and cnfidential. We are cmmitted t prtecting the privacy f PHI. This Ntice applies t all PHI generated r received by the Cmpany. It als applies t all emplyees f the Cmpany wh may have access t r are required t use yur PHI fr any f the purpses described in this Ntice, as well as persns having a business assciate agreement with the Cmpany. WE ARE REQUIRED BY LAW TO: make sure that yur PHI is kept cnfidential; give yu this Ntice f ur privacy practices with respect t PHI abut yu; abide by the terms f the Ntice, as currently in effect; and ntify yu in the event that there is a breach f yur unsecured PHI. I. USES AND DISCLOSURES OF PHI The fllwing describes ways that we are permitted by HIPAA t use and disclse yur PHI. Fr each categry we will explain what we mean and give sme examples. Nt every use r disclsure is listed and the examples are nt exhaustive. This explanatin is prvided fr yur general infrmatin nly. Disclsure f yur PHI fr the purpses described in this Ntice may be made in writing, rally, r electrnically, by facsimile r by any ther means. A. TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS 1. Fr Treatment. We may use and disclse PHI abut yu t prvide, crdinate, r manage yur treatment and related services. This includes the crdinatin r management f yur health care with a third party fr treatment purpses. We may disclse PHI abut yu t dctrs, nurses, technicians, cunselrs, medical students, r ther persnnel wh are invlved in taking care f yu. Fr example, we may disclse yur PHI t any health care prvider wh has referred yu t us fr treatment. We may als disclse PHI abut yu fr treatment activities f ther health care prviders. Fr example, if yur family dctr has determined that yu need t be seen by the Cmpany, we may send him a reprt f ur diagnstic findings and ur plan f treatment t assist him in prviding yu with care. 2. Fr Payment. We may use and disclse PHI abut yu s that the treatment and services yu receive at the Cmpany may be billed t, and payment may be cllected frm yu, an insurance cmpany r ther third party. Fr example, we may need t give yur health plan infrmatin abut treatment yu received s yur health plan will pay us r reimburse yu fr that treatment. We may als tell yur health plan abut a treatment yu are ging t receive in rder t btain prir apprval r t determine whether yur plan will cver the treatment. We may als disclse PHI t anther prvider invlved in yur care fr the ther prvider s payment activities. This might include disclsures f demgraphic infrmatin t labratry r x-ray prviders fr payment f their services. 3. Fr Health Care Operatins. We may use and disclse PHI abut yu fr ur wn peratins. These uses and disclsures are necessary t run the Cmpany and prvide quality care t patients. Fr example, we may use PHI t review ur treatment and services and t evaluate the perfrmance f ur staff in caring fr yu. We may cmbine PHI abut many f ur patients t decide what additinal services we shuld ffer, what services are nt needed, and whether certain new treatments are effective. We may als disclse infrmatin t the Cmpany persnnel fr training prgrams. We may cmbine the PHI we have with PHI frm ther prviders t cmpare hw we are ding and see where we can make imprvements in the care and services we ffer. We may smetimes remve infrmatin that identifies yu frm this set f PHI s thers may use it t study health care and health care delivery withut learning wh the specific patients are. We may als prvide yur PHI t ur accuntants, attrneys, cnsultants and thers in rder t perate the Cmpany and t make sure we are cmplying with the laws that affect us. We may als disclse PHI t anther cvered entity fr certain health care peratins f that entity, if the entity either has r had a relatinship with yu, such as a treatment relatinship, and if the PHI pertains t such relatinship. Such disclsure is limited t certain activities f the ther entity, including quality assessment and related activities, prtcl develpment, care crdinatin, cntacting health care prviders and patients with infrmatin abut treatment alternatives, and reviewing the cmpetency and qualificatins f health care prfessinals. We may use r disclse yur PHI in rder fr third party "business assciates" t perfrm varius activities invlving treatment, payment r peratins n behalf f ur Cmpany. Hwever, whenever ur arrangement between the Cmpany and a business assciate invlves the use r disclsure f yur PHI, we will have a written cntract, as and when required by law, that cntains terms t prtect the privacy f yur PHI. B. USES AND DISCLOSURES BEYOND TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS PERMITTED WITHOUT AUTHORIZATION OR OPPORTUNITY TO OBJECT Federal privacy rules allw us t use r disclsure yur PHI withut yur permissin r authrizatin fr a number f reasns including the fllwing: 1. Treatment Alternatives. We may use and disclse PHI abut yu t tell yu abut r recmmend pssible treatment ptins r alternatives that may be f interest t yu.

14 2. Health-Related Benefits and Services. We may use and disclse PHI abut yu t tell yu abut health-related benefits r services that may be f interest t yu. Fr example, we may send yu a packet f infrmatin and registratin frms prir t yur first appintment with ne f ur dctrs. 3. Appintment and Patient Recall Reminders. We may use and disclse PHI abut yu t cntact yu as a reminder yu have an appintment r that yu are due t receive peridic care. This cntact may be by phne, in writing, autmated appintment system, , r therwise and may invlve leaving an , message ver an answering machine r which culd (ptentially) be received r intercepted by thers. 4. As Required by Law. We may disclse PHI abut yu when required t d s by, and if we limit the disclsure as required by, federal, state r lcal law. 5. T Avert a Serius Threat t Health r Safety. We may use and disclse limited PHI abut yu when we believe it is necessary t prevent a serius threat t yur health r safety r the health and safety f the public r anther persn. Any disclsure, hwever, wuld nly be t smene able t help prevent the threat. 6. Eye, Organ and Tissue Dnatin. If yu are an rgan dnr, we may disclse PHI abut yu t rganizatins that handle eye rgan r tissue transplantatin r t an rgan dnatin bank, as necessary t facilitate rgan r tissue dnatin and transplantatin. 7. Military and Veterans. If yu are a member f the armed frces, we may disclse PHI abut yu as required by military cmmand authrities in certain situatins. We may als disclse PHI abut freign military persnnel t the apprpriate freign military authrity. 8. Wrker s Cmpensatin. We may disclse PHI abut yu fr wrkers cmpensatin r similar prgrams as required by law. These prgrams prvide benefits fr wrk-related injuries r illness withut regard t fault. 9. Public Health Activities. We may disclse PHI abut yu t a public health authrity fr public health activities. These activities generally include the fllwing: t prevent, cntrl, r reprt disease, injury r disability; t reprt vital events such as births and deaths; t reprt child abuse r neglect; t reprt reactins t medicatins r prblems with prducts, track FDA regulated prducts, enable prduct recalls, repairs r replacements and t cnduct pst marketing surveillance; t ntify peple f recalls f prducts they may be using; t ntify a persn wh may have been expsed t a disease r may be at risk fr cntracting r spreading a disease r cnditin. 10. Schls. We may disclse PHI abut yu (r yur child) t a schl if yu (r yur child) are a student r a prspective student, and: (i) the PHI is limited t prf f immunizatin; (ii) the schl is required by law t have prf f such immunizatin prir t admissin; and (iii) we btain and dcument yur agreement t the disclsure. 11. Emergency Situatins. We may disclse PHI abut yu t an rganizatin assisting in a disaster relief effrt r in an emergency situatin s that yur family r thers can be ntified abut yur general cnditin and lcatin r death. 12. Victims f Abuse, Neglect and Dmestic Vilence. We may use and disclse PHI abut yu t ntify the apprpriate gvernment authrities if we believe yu have been a victim f abuse, neglect r dmestic vilence, but we will nly make this disclsure; (i) if yu agree; (ii) when required by law; r (iii) when authrized by law and certain ther cnditins are met. 13. Health Oversight Activities. We may disclse PHI t a health versight agency fr activities authrized by law. These versight activities include, fr example, audits, investigatins, inspectins and licensure. These activities are necessary fr the gvernment t mnitr the health care system, gvernment prgrams and cmpliance with civil rights laws and ther activities necessary fr versight f the health care system, gvernment benefit payments and entities subject t gvernment regulatin. This des nt include disclsure fr investigatins r ther activities in which yu are a subject f the investigatin and which d nt arise ut f the receipt f health care, a claim fr public health benefits r the qualificatin fr receipt f public health benefits r services. 14. Lawsuits and Administrative Prceedings. We may disclse PHI abut yu in respnse t a curt r administrative rder. We may als disclse PHI pursuant t a subpena, discvery request, r ther lawful prcess by smene else invlved in the dispute, but nly if effrts have been made by the party requesting the infrmatin t tell yu abut the request r t btain an rder prtecting the infrmatin requested. We may als use such infrmatin t defend urselves r any persnnel f the Cmpany in any actual r threatened actin. 15. Law Enfrcement Purpses. We may disclse PHI if asked t d s by a law enfrcement fficial: In respnse t a curt rder, subpena, warrant, summns, grand jury subpenas r similar prcess; T identify r lcate a suspect, fugitive, material witness, r a missing persn; Abut the victim f a crime if the individual agrees and, under certain limited circumstances, where we are unable btain the persn s agreement; Abut a death we believe may be the result f criminal cnduct; Abut criminal cnduct at the Cmpany; In emergency circumstances t reprt a crime, the lcatin f the crime r victims, r the identity, descriptin r lcatin f the persn wh cmmitted the crime; Abut certain types f wund r physical injuries as required by law.

15 16. Victims f a Crime: We may disclse yur PHI if asked by a law enfrcement fficial, if (i) yu are suspected t be a victim f a crime, (ii) yu agree t the disclsure r (iii) we are unable t btain yur agreement because f incapacity r ther emergency circumstances. Hwever, the law enfrcement fficial must represent that the infrmatin is needed t determine whether a vilatin f law by a persn ther than yu has ccurred, and the infrmatin is nt intended t be used against yu, that immediate law enfrcement activity depends n the disclsure and wuld be materially and adversely affected by waiting until yu are able t agree, and we determine that the disclsure is in yur best interest in the exercise f prfessinal judgment. 17. Crners, Medical Examiners and Funeral Directrs. We may disclse PHI t a crner r medical examiner. This may be necessary, fr example, t identify a deceased persn r determine the cause f death r fr the crner r medical examiner t perfrm ther duties authrized by law. We may als disclse PHI abut patients f the Cmpany t funeral directrs as necessary t carry ut their duties. 18. Natinal Security and Intelligence Activities. We may disclse PHI abut yu t authrized federal fficials s they may cnduct intelligence, cunter-intelligence and ther activities authrized by the Natinal Security Act. 19. Prtective Services fr the President and Others. We may disclsure PHI abut yu t authrized federal fficials s they may prvide prtectin t the President, ther authrized persns r freign heads f state r cnduct special investigatins. 20. Inmates. If yu are an inmate f a crrectinal institutin r under the custdy f a law enfrcement fficial, we may disclse PHI abut yu t the crrectinal institutin r law enfrcement fficial. This disclsure may be necessary (i) fr the institutin t prvide yu with health care; (ii) t prtect yur health and safety r the health and safety f thers; r (iii) fr the safety and security f the crrectinal institutin. 21. Research. Under certain circumstances, we may use and disclse PHI abut yu fr research purpses regarding medicatins, efficiency f treatment prtcls and the like. All research prjects are subject t an apprval prcess, which evaluates a prpsed research prject and its use f PHI. Befre we use r disclse PHI fr research, the prject will have been apprved thrugh this research apprval prcess by an Institutinal Review Bard ( IRB ) r a Privacy Bard. We will btain an Authrizatin frm yu befre using r disclsing yur individually PHI unless the authrizatin requirement has been altered r waived by the IRB r Privacy Bard. If reasnably pssible, we may make the infrmatin nn-identifiable t a specific patient. If the infrmatin has been sufficiently de-identified, an Authrizatin fr the use r disclsure is nt required. If we btain certain representatins frm the researcher, we may use and disclse PHI abut yu fr the researcher t prepare prtcls preparatry t research. 22. Incidental Disclsures. We may use and disclse PHI abut yu incident t therwise permitted r required uses and disclsures. Fr example, we may ask yu t sign a sign-in sheet when yu arrive fr an appintment at the Cmpany as an incident t the treatment prcess. 23. T the Secretary f the Department f Health and Human Services. We are required t disclse PHI abut yu when requested by the Secretary f the Department f Health and Human Services in rder t investigate r determine ur cmpliance with HIPAA. C. USES AND DISCLOSURES PERMITTED WITHOUT AUTHORIZATION BUT WITH YOUR OPPORTUNITY TO OBJECT. 1. Disclsures t Family, Friends r Others Invlved in Yur Case. We may disclse yur PHI t yur family members, t a clse persnal friend r ther persn that yu identify if it is directly relevant t the persn s invlvement in yur care r payment related t yur care. We may als disclse PHI cncerning yur lcatin, cnditin r death in cnnectin with trying t lcate r ntify family members r thers invlved in yur care. Generally, we will btain yur verbal agreement befre using r disclsing PHI in this way. Hwever, under certain circumstances, such as in an emergency situatin, we may make these uses and disclsures withut yur express agreement if we feel, in the exercise f prfessinal judgment, that it is in yur best interest. 2. Objectin t Disclsures. Yu may bject t these disclsures by indicating the names and relatinship f individuals that yu d nt want t receive yur medical infrmatin n the Acknwledgement f Receipt f Ntice f Privacy Practices frm. If yu are present and d nt bject t these disclsures, r if yu are present and we can infer frm the circumstances that yu d nt bject, r if yu are nt present r able t bject and we determine, in the exercise f ur prfessinal judgment, that it is in yur best interests fr us t make disclsure f infrmatin that is directly relevant t the persn s invlvement with yur care, we may disclse yur PHI fr such purpse. D. USES AND DISCLOSURES WHICH YOU MAY AUTHORIZE 1. Psychtherapy Ntes. We must btain a valid authrizatin frm yu fr any use r disclsure f psychtherapy ntes, unless such use r disclsure is: (i) necessary t carry ut treatment, payment r health care peratins; r (ii) therwise required by law. 2. Marketing. We must btain a valid authrizatin frm yu fr any use r disclsure f yur PHI fr marketing purpses unless the marketing cmmunicatin is in the frm f a face-t-face cmmunicatin; is a prmtinal gift f nminal value; r is a refill reminder r ther cmmunicatin regarding a drug r bilgical currently being prescribed. 3. Sale f PHI. We must btain a valid authrizatin frm yu fr any use r disclsure f yur PHI which results in a sale f yur PHI fr which the Cmpany receives financial remuneratin. Other uses and disclsures f PHI nt described in this Ntice r in the laws that apply t us will be made nly with yur written authrizatin. If yu prvide us with a written authrizatin t use r disclse PHI abut yu, yu may revke that authrizatin, in writing, at any time t the extent that we haven t already taken any actin relying n the authrizatin. If yu revke yur authrizatin, we will n lnger disclse PHI abut yu pursuant t that revked authrizatin. Yu understand that we are unable t take back any disclsures we have already made with yur authrizatin, and that we are required t retain ur recrds f the care that we prvided yu.

16 II. PATIENT RIGHTS THIS SECTION DESCRIBES YOUR RIGHTS AND THE OBLIGATIONS OF THE COMPANY REGARDING THE USE AND DISCLOSURE OF YOUR PHI. Yu have the fllwing rights regarding PHI we maintain abut yu: 1. Right t Inspect and Cpy. Yu have the right t inspect and cpy yur PHI that is cntained in a designated recrd set. A designated recrd set cntains medical and billing recrds and any ther recrds that the Cmpany uses fr making decisins abut yur care. This des nt include infrmatin cmpiled in reasnable anticipatin f, r fr use in, a civil, criminal, r administrative actin r prceeding; and PHI that is subject t a law that prhibits access t PHI r infrmatin which yur dctr identifies as ptentially harmful t yu r thers if it is released. T inspect and cpy PHI in yur designated recrd set, yu must submit yur request in writing t ur Privacy Officer, as identified n the last page f this Ntice. If yu request a cpy f the infrmatin, we may charge a cst-based fee fr the csts f cpying, mailing r ther supplies (tapes, diskettes, etc.) assciated with yur request. We will respnd t yu within 15 days after receiving yur written request. We may deny yur request t inspect r cpy, in certain limited circumstances. If yu are denied access t yur PHI because a physician has determined it may be dangerus t yu r anther persn, yu may request that the denial be reviewed. Anther licensed health care prfessinal chsen by the Cmpany will review yur request and the denial. The persn cnducting the review will nt have participated in the first decisin t deny yur request. In the alternative, yu may chse anther prvider t review the material at yur expense. We will cmply with the utcme f that review. 2. Right t Amend. If yu feel that the PHI in yur designated recrd set is incrrect r incmplete, yu may ask us t amend the infrmatin. Yu have the right t request an amendment fr as lng as the infrmatin is kept by the Cmpany. T request an amendment, yur request must be made in writing and submitted t the Cmpany's Privacy Officer, as identified n the last page f this Ntice. In additin, yu must prvide: the reasns fr the request; a descriptin f the prblem hw the infrmatin is incrrect r incmplete; a descriptin f the administrative infrmatin t be crrected; and/r medical infrmatin t be amended including the surce if knwn, date and prvider f service; the specific wrding t make the entry crrect/cmplete; identificatin f persn(s) wh need t be advised f the amendment, including cntact infrmatin and authrizatin t advise them if necessary. The request must be dated and signed by yu. We will act n yur request within 60 days f receiving yur request. If we are unable t act n the request within the 60-day perid, we may extend the time fr actin by n mre than 30 days by prviding yu, within the initial 60 days, with a written statement f the reasns fr the delay and the date by which we will cmplete ur actin n yur request. We may deny yur request fr an amendment if it is nt made in writing r des nt include a reasn t supprt the request. In additin, we may deny yur request if yu ask us t amend infrmatin that: Was nt created by us, unless the persn r entity that created the infrmatin is n lnger available t make the amendment; Is nt part f the designated recrd set kept by r fr the Cmpany; Is nt part f the infrmatin which yu wuld be permitted t inspect r cpy; r Is accurate and cmplete. Our written denial will state the reasns fr the denial and explain yur right t file a written statement f disagreement with the denial. If yu dn t file ne, yu have the right t ask that yur request and ur denial be attached t all future disclsures f yur PHI. If we apprve yur request, we will make the change t yur PHI, tell yu we have dne it, and tell thers whm yu identify and authrize us t tell that need t knw abut the change t yur PHI. 3. Right t an Accunting f Disclsures. Yu have the right t request an accunting f certain disclsures f yur PHI. This right applies t disclsures fr purpses ther than treatment, payment r health care peratins as described in this Ntice. We are als nt required t accunt fr disclsures made t yu, disclsures that yu agreed t by signing an authrizatin, disclsures fr a facility directry, t friends r family members invlved in yur care, incidental disclsures, r certain ther disclsures we are permitted t make withut yur authrizatin. T request this accunting f disclsures, yu must submit yur request in writing t ur Privacy Officer, as identified n the last page f this Ntice. Yur request must state a time perid, which may nt be lnger than six years and may nt include dates befre April 14, Yur request shuld indicate in what frm yu want the list (fr example, n paper r electrnically). The first list yu request within a 12-mnth perid will be free. Fr additinal lists, we may charge yu fr the csts invlved and yu may chse t withdraw r mdify yur request at that time, befre any csts are incurred. We will respnd within 60 days f receiving yur request. If we are unable t respnd within the 60 day perid, we may extend the perid fr up t an additinal 30 days if we send yu a written statement f the reasns fr the delay within the initial 60 day perid. In certain situatins we are required by HIPAA t temprarily suspend yur right t receive an accunting f disclsures. 4. Right t Request Restrictins. Yu have the right t request a restrictin r limitatin n the PHI we use r disclse abut yu fr treatment, payment r health care peratins. Yu als have the right t request a limit n the PHI we disclse abut yu t smene wh is invlved in yur care, like a family member r friend r fr ntificatin purpses. Fr example, yu culd ask that we nt use r disclse infrmatin abut a particular treatment that yu had. We are nt required t agree t yur request, except fr disclsures t a health plan which wuld have been made in the curse f carrying ut the Cmpany s payment r healthcare peratins, and pertain slely t a healthcare item r service fr which the Cmpany has been paid ut-f-pcket in full. If we d agree, we will cmply with yur request unless the infrmatin is needed t prvide yu emergency treatment r unless the infrmatin is required t be disclsed by law. T request such restrictins, yu must make yur request in writing t ur Privacy Officer, as identified n the last page f this Ntice. In yur request, yu must tell us (i) what infrmatin yu want t limit; (ii) whether yu want t limit ur use, disclsure r bth; and (iii) t whm yu want the limits t apply, fr example, disclsures t yur spuse r children.

17 We may terminate ur agreement t a restrictin, except fr a restrictin relating t disclsures t a health plan which wuld have been made in the curse f carrying ut the Cmpany s payment r healthcare peratins, and pertain slely t a healthcare item r service fr which the Cmpany has been paid ut-f-pcket in full, if: yu agree t r request the terminatin in writing; yu rally agree t the terminatin and the ral agreement is dcumented; r we infrm yu that we are terminating the agreement, except that such terminatin is nly effective with respect t prtected health infrmatin created r received after we have s infrmed yu. 5. Right t Request Alternative Cmmunicatins. Yu have the right t request that we cmmunicate with yu abut medical matters in a certain way r at a certain lcatin. Fr example, yu can ask that we nly cntact yu at wrk r by mail, that we nt leave vice mail r , r the like. T request cnfidential cmmunicatins, yu must make yur request in writing t ur Privacy Officer, as identified n the last page f this Ntice. We will nt ask yu the reasn fr yur request. We will accmmdate all reasnable requests as lng as we can easily prvide it in the frmat yu requested. Yur request must specify hw r where yu wish t be cntacted. 6. Right t a Paper Cpy f this Ntice. Yu have the right t a paper cpy f this Ntice. Yu may ask us t give yu a cpy f this Ntice at any time. Even if yu have agreed t receive this Ntice electrnically, yu are still entitled t a paper cpy f this Ntice. Yu may als view a cpy f this Ntice n ur web site. 7. The Right T Get This Ntice by . Yu have the right t get a cpy f this Ntice by . Even if yu have agreed t receive this Ntice via , yu als have the right t request a paper cpy f this Ntice. T btain a paper cpy f this Ntice cntact ur Privacy Officer, as identified n the last page f this Ntice. III. CHANGES TO THIS NOTICE We reserve the right t change this Ntice at any time. We reserve the right t make the revised r changed Ntice effective fr prtected health infrmatin that we already have abut yu as well as any such infrmatin we receive in the future. We will pst a cpy f the current Ntice in the administrative area at the Cmpany. The Ntice will cntain n the first page, in the tp right-hand crner, and at the end f the Ntice, the effective date. In additin, each time yu register at, r are admitted t, the Cmpany fr treatment r health care services, yu may request a cpy f the current Ntice in effect. Yu may als view a cpy f the current Ntice n ur web site at IV. COMPLAINTS If yu believe yur privacy rights have been vilated, yu may file a cmplaint with the Cmpany r the Department f Health and Human Services. T file a cmplaint with us, please cntact ur HIPAA Privacy Officer at the address and telephne number nted belw. All cmplaints must be submitted in writing. Yu will nt be penalized fr filing a cmplaint. V. PRIVACY OFFICER The Cmpany s Privacy Officer is Kimberly Rbertsn, wh may be reached at (540) VI. EFFECTIVE DATE This Ntice is effective as f Nvember 1, 2013