THIS NOTICE TELLS YOU HOW HEALTH AND SUBSTANCE USE DISORDER INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET THISINFORMATION. PLEASE REVIEW THIS CAREFULLY

OUR PLEDGE REGARDING HEALTH INFORMATION

SummitStone Health Partners, SunriseCommunity Health Center, Loveland Community Health Center, the Health District of Northern Larimer County, Salud Family Health Center, Family Medicine Center, Associates In Family Medicine, and Genoa, A QoL Healthcare Company, are required by law to maintain the privacy of your health information and to provide you with notice of our legal duties and privacy practices with respect to your health information. Additionally, we are required to abide by the terms of the Notice of Privacy Practices currently in effect.

ORGANIZED HEALTH CARE ARRANGEMENT

As permitted by law, SummitStone Health Partners, Sunrise Community Health Center, Loveland Community Health Center, the Health District of Northern Larimer County, Salud Family Health Center, Family Medicine Center, Associates in Family Medicine, and Genoa, A QoL Healthcare Company have agreed to share your health information among themselves for the purposes of treatment, payment, and health care operations. This enables us to better address your health careneeds.

USES AND DISCLOSURES OF PROTECTED INFORMATION

Treatment, Payment, and Health Care Operations: We will use and give out your physical and mental health information to provide you with health care treatments, to get paid for our services, and to help us operate. For example:

Treatment refers to the provision, coordination, or management of health care and related services by one or more health care providers. For example, staff involved with your care may use your information to plan your course of treatment and consult with other staff to ensure the most appropriate methods are being used to assist you.

Payment refers to the activities undertaken by a health care provider to obtain or provide reimbursement for the provision of health care. For example, your information will be used to develop accounts receivable information, bill you, and with your consent, provide information to your insurance company for services provided. The information provided to insurers and other third-party payors may include information that identifies you, aswell as your diagnosis, type of service, date of service, provider name/identifier, and other information about your condition and treatment. If you are covered by Medicaid, information will be provided to the State of Colorado’s Medicaid program, including but not limited to your treatment, condition, diagnosis, and services received.

Health Care Operations refers to activities undertaken that are regular functions of management and administrative activities. For example, your health information may be used in monitoring service quality, staff training and evaluation, medical reviews, legal services, auditing function, compliance programs, business planning, and accreditation, certification, licensing and credentialing activities.

Appointment Reminders: We may use and disclose your health information to remind you of appointments, recommended exams, or prescription refills.

Treatment Alternatives: We may use and disclose your health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Health-Related Benefits and Services: Wemay use and disclose your health information to tell you about health-related benefits or services.

Individuals Involved in Your Care or Payment for Your Care: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your health information that directly relates to that person’s involvement in your health care or payment related to 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.

Other Uses and Disclosures Allowed or Required by Law: We may use or give out your health information for the following purposes under limited circumstances:

• To people who are involved in your care or who help pay for your care, such as your family, your close personal friends, or any other
  person chosen by you, to notify them of your location, general health, and to assist you in your health care (such as to pick-up medicine or help with follow-up care);
• To appropriate government authorities if we believe a patient has been the victim of abuse, neglect, or domestic violence (when required by law);
• To government agencies that oversee us (such as license and certification inspectors);
• To government agencies that have the right to receive and collect health information (such as to control disease outbreaks);
• For court proceedings (such as in response to a court order or other request by ajudge);
• To workers’ compensation programs when your health problem is from a work-relatedinjury;
• For law enforcement purposes (such as providing limited information to find a suspect or missing person);
• To coroners, medical examiners, and funeral directors to allow them to carry out theirduties;
• To organ donor agencies (subject to applicablelaws);
• For research studies that meet all privacy law requirements (such as research to stop adisease);
• To avoid a serious threat to the health or safety ofothers;
• To authorized public or private entities to assist in disaster reliefefforts;
• To government agencies for intelligence and national security activities (when required by law);
• To government agencies so they may protect the President, foreign heads of state, and other persons;
• To government agencies if there is a threat to a school or its employees and personnel;
• To correctional institutions, if you are an inmate;
• To the armed forces, if you are a member of the armedforces;
• To pharmacies for those that needprescriptions;
• To foreign military authorities, if you are a member of a foreign militaryforce;
• Uses and disclosure of PHI for marketing purposes, as well as disclosures that constitute a sale of PHI, require authorization by the individual;
• Other uses and disclosures not described in this notice will be made only with authorization from the individual;
• Individuals have the right to opt out of receiving fundraising communications;
• Individuals have a right to restrict certain disclosures of protected health information to a health plan where the individual pays
  out of pocket in full for the healthcare item or service;
• Affected individuals have a rightto be notified following a breach of unsecured protected health information;
• To our business associates that help us perform required tasks, such as our accountants, computer consultants, and billing
  companies (only if the business associate agreesin writing to keep your health informationconfidentialasrequiredbylaw);and
• For any other purpose required or allowed bylaw.

We will share your health information with health care professionals not on our staff, such as other healthcare providers and hospital staff, who help care for you. This information may be shared via fax, paper or electronic formats. We also participate in a health information exchange (Colorado Regional Health Information Organization or CORHIO), which enables healthcare providers to share a database containing your health information for treatment purposes and enables the delivery of better, more efficient care to you. However, you may opt out of participation in CORHIO at any time by notifying our staff, who will then provide you with the forms to do so.

Stricter Requirements for Substance Use Disorder Treatment Information: Use and disclosure of specific types of health information, such as substance use disorder treatment information, are subject to stricter requirements than listed in this Notice. However, a few circumstances still exist in which these types of health information may be used or disclosed without your written permission.

SUBSTANCE ABUSE DISORDER TREATMENT INFORMATION

The confidentiality of substance use disorder patient records maintained by our programs is protected by HIPAA and Federal law and regulations at 42 CFR Part 2. Generally, we may not say to a person outside a program that a patient attends a program or disclose any information identifying a patient as having a substance use disorder unless:

• The patient consents in writing;
• The disclosure is allowed by court order; or
• The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation.

Violation of the Federal substance use disorder patient records law and regulations by a program is a crime. Suspected violations may be reported to appropriate authorities in accordance with Federal regulations. Federal law and regulations do not protect any information about a crime committed by a patient either at the program or against any person who works for the program, or about any threat to commit such crime. Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under State law to appropriate State or local authorities.

OTHER USES AND DISCLOSURES REQUIRING YOUR WRITTEN PERMISSION

Except as stated above, we will make other uses and disclosures of your health information only after getting your written permission on an Authorization or Release of Information form. If you authorize a use not contained in this notice, you may revoke your authorization at any time by notifying us in writing that you wish to do so.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

Subject to certain legal limits, you have rights regarding the use and disclosure of your health information, including the rights to:

• Request restrictions on certain uses and disclosures of your health information. We do not have to agree to that request, and there are certain limits to any restriction which will be provided to you at the time of your request.
• Receive confidential communications of your health information. You have the right to request that you receive communications of protected health information by alternative means or at alternative locations.
• Inspect and copy your health information. There are some limitations to this right which will be provided to you at the time of your request if any such limitationapplies (e.g., your medical records may only be kept on file for seven (7) years.
• Request an amendment to your health information. We are not required to amend the record if it is determined that the record is accurate and complete. There are other exceptions which will be provided to you at the time of your request, if relevant, along with the appeal process available to you.
• Receive an accounting of our uses and disclosures of your health information. In addition, the accounting does not include disclosures made to you, disclosures made pursuant to a signed Authorization or Release of Information, or disclosures made prior to April 14,2003.
• Obtain a copy of this Notice of PrivacyPractices.

ADDITIONAL INFORMATION

• Privacy Laws: We are required by State and Federal law to maintain the privacy of protected health information. In
  addition, we are required by law to provide clients with notice of its legal duties and privacy practices with respect to protected health information. That is the purpose of the Notice.
• Terms of the Notice and Changes to the Notice: We are required to abide by the terms of this Notice, or any amended Notice that may follow. We reserve the right to change the terms of this Notice and to make the new Notice provisions effective for all protected health information that we maintain. When the Notice is revised, the revised Notice will be posted in all service delivery sites and will be available upon request

QUESTIONS, CONCERNS, AND COMPLAINTS

If you have any questions or concerns about this Notice, or believe your privacy rights have been violated, you may contact any of the organizations listed below:

• To file a complaint with the SummitStone Health Partners, contact the Client and Family Advocate at (970) 494-4359. The address is 4102 South Timberline Road, Fort Collins, CO 80525.
• To file a complaint with the Health District of Northern Larimer County, contact the Privacy Officer at (970) 224-5209. The address is 120 Bristlecone Street, Fort Collins, CO 80524.
• To file a complaint with the Secretary of Health and Human Services, contact the Office for Civil Rights, U.S. Department of Health and Human Services, 1961 Stout Street, Room 1426, Denver, CO 80294; phone: (303) 844-2024; fax: (303) 844-2025.
• To file a complaint with Genoa, A QoL Healthcare Company, contact the Pharmacy Administrator at (412) 613-4434. The address is 4900 Perry Highway, Building 2, Pittsburgh, PA 15229.
• To file a complaint with Sunrise or Loveland Community Health Centers, call (970) 292-1522. The address is 302 SE 3rd Street #150, Loveland, CO 80538.
• To file a complaint with Estes Park Salud, call the Business Manager at (970) 586-9230, or if unable to resolve the issue locally all complaints are referred to the Director of Patient Services, at (303) 892-6401. The address is Center Manager, Estes Park Salud, 1950 Redtail Hawk Dr., Estes Park, CO 80517.
• To file a complaint with the Associates in Family Medicine, contact the Compliance Officer at (970) 495- 6201. The address is 3702 Automation Way, Suite 103, Fort Collins, CO 80525.
• To file a complaint with Family Medicine Center, contact the Patient Representative at (970) 495-7346.

WE WILL NOT RETALIATE AGAINST YOU FOR FILING A COMPLAINT.