This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review carefully.

MPC is dedicated to maintaining the privacy of your personal health information (PHI) as a key element of providing professional care. For additional details, please direct inquiries to MPC’s CEO, a U.S. law designed to provide privacy standards to protect patients' medical records and other health information provided to health plans, doctors, hospitals, and other health care providers.

After you have read this notice, we ask you to sign the Consent Statement (aka Intake Release) via electronic signature to let MPC use and share information for the treatment, payment, and daily operations of the clinic (TPO):

• Treatment allows providers to share information to provide the best care possible.
• Payment allows MPC to obtain payment from insurance companies who are also bound by strict privacy laws.
• Operations permit MPC’s administrative staff to also support your care through scheduling, transportation, etc.

This Consent must be signed in order for MPC to treat you.

If MPC needs to use or disclose (send, share, release) your medical information for any purposes, we will discuss this with you and ask you to sign a specific form (Release of Information aka ROI) authorizing to do so.

Although MPC will endeavor to keep your PHI private, there are exceptions:

• Some lawsuits and legal or court proceedings.
• If a law enforcement official requires use to do so.
• For Worker’s Compensation or similar benefit.

Only your medical records may be released in the above situations. Personal therapy notes and therapeutic admission summaries are governed by specific HIPAA clauses and state of Maryland regulations that prevents the release of personal therapy documentation. MPC may provide a written summary by your therapist and may only address your participation in treatment.

The only exceptions to these guidelines:

• In the event of an emergency when there is a serious threat to your health and safety or the health and safety of another individual or the public. Your information will only be shared with a person or organization that is able to prevent or reduce the threat.
• MPC’s participation in the Chesapeake Regional Information System for our Patients (CRISP), a regional health information exchange serving Maryland and Washington, D.C. As permitted by law, your health information will be shared with this exchange in order to provide faster access, better coordination of care and assist providers and public health officials in making more informed decisions. You may “opt-out” and disable access to your health information available through CRISP by calling 1-877-952-7477 or completing and submitting an Opt-Out form to CRISP by mail, fax or through their website at www.crisphealth.org. Public health reporting and Controlled Dangerous Substances information, as part of the Maryland Prescription Drug Monitoring Program (PDMP), will still be available to providers.

Your rights regarding your PHI:

1. You may ask to communicate about your health and related issues in a particular way or at a certain place which is more private for you. Example, you may ask MPC to call you at home and not at work to schedule or cancel an appointment. MPC will never leave a message mentioning behavioral health. The message will simply say MPC.
2. You have the right to request MPC to limit what MPC tells people and entities involved in your care without an ROI, which includes family member and friends, unless there is a safety emergency.
3. You have the right to look at your medical information including billing records in paragraph two. There may be an administrative charge for MPC to print your records and MPC has up to 10 days to respond to such requests. A written request is mandatory when requesting records. These are available at the office front desk.
4. If you believe the information in your medical records is incorrect or missing important information, you may request some changes (called amending) to your PHI. You must request this information in writing and send to MPC’s CEO and explain the reasoning. Such requests will not be kept in your record but will remain on file with the CEO and will not be disclosed. Changes will not be granted if there is a serious threat to the safety of yourself or others.
5. You have a right to a copy of this notice, and the entire MPC new patient paperwork. If we change the NPP, MPC will post the new version in our waiting area.
6. You have the right to file a complaint if you believe your privacy rights have been violated. You may file a complaint with our CEO and with the Secretary of the Department of Health. All complaints must be in writing. Filing a complaint will not change the health care we provide to you in anyway.

If you have any questions about MPC’s NPP, please contact our CEO.

• You have the right to receive treatment free of discrimination on the basis of race, sex, sexual orientation, age, creed, mental or physical handicapped status, national origin, marital status, or religious or political opinions or affiliations.
• You have the right not to be exploited for fiduciary gains by any MPC provider or member.
• You have the right to be treated with courtesy, respect, and full recognition of your human dignity and individuality.
• You have the right to a treatment plan and active participation in its development.
• You have the right to receive treatment according to your treatment plan.
• You have the right to be free from mental, physical, or sexual abuse.
• You have the right to legal redress in the event of any abuse.
• Recording devices are not employed at You have a right to know if their use will be introduced.
• You have a right to know about the risks and/or side effects of your medication(s) and any prescribed medical procedure.
• You have the right to refuse medication.
• You have the right to refuse treatment.
• You are entitled to be informed of alternative types of treatment.
• You have a right to receive treatment and services free of neglect.
• You have the right to be treated free of humiliation, exploration, physical and sexual abuse, harassment and physical punishment, or any other type of indignity.
• You have the right to receive treatment and other services in the least restrictive environment possible.
• You have the right to be free from any means of coercion, discipline, constraint or retaliation by staff, including free from restraint and seclusion.
• You have the right to report any concerns you may have with your treatment and file a grievance if you feel the need to do so.
• You have a right to know and understand the grievance process and procedures.
• You have a right to be notified regarding the outcome and solution of your grievance.
• You have the right to no retaliation if a grievance is filed.
• You have a right to formulate an “Advanced Directive.”
• You are not required to have an “Advanced Directive” to receive treatment or services.
• You have the right to every consideration of confidentiality regarding your services and personal information.
• You have the right to know which staff members are directly responsible for your care and have a list of expected services.
• You have the right to full information on the availability of known financial resources for your healthcare.
• You have the right to access other adjunctive services and resources in the community, to included but not limited to: legal services, dental care, food closets, clothing closets, shelters, employment fairs, etc.
• You have the right to MPC’s cooperation with you and/or your attorney in matters relating to your condition or its treatment (e.g. pursuit of disability or other entitlements).
• You have the right to access your medical record.
• You have the right to petition for a change in your medical The change will be taken under review by the provider/treatment team and determined if appropriate.
• You have the right to bring prescription medications into the MPC office at the request of your medical provider(s). You also have the right to bring essential, medically necessary, somatic prescription medications into the MPC office.

Each patient has the right to present grievances regarding their treatment without reprisal. Follow the steps below when addressing these situations:

1. The patient, personally or through others, may present grievances verbally or in writing to:
   • Their treating provider
2. Grievances shall be documented in the patient’s chart.
3. Grievances shall be initially referred to the treating provider(s) for resolution. The provider(s) shall:
   • Investigate and respond to the grievance within two (2) working days.
   • Provide the patient with a response in the medium (verbal or written) in which the grievance was submitted.
   • The response shall include a description of the patients’ avenue of appeal.
4. Appeals shall be referred to the member’s director, or if the member is a director, to the CEO. The individual shall respond within two (2) business days as above.
5. Subsequent appeals shall be routed to the CEO and Medical Director following the process above.
6. If satisfaction of the grievance cannot be accomplished within the confines of MPC, it shall be appealed to The Department of Family Services/Core Service Agency in the county where the patient resides.

Patients may be discharged or transferred from MPC treatment if they:

• Indicate an unwillingness to continue or unilaterally suspend participation in treatment;
• Move from the area(s) serviced by MPC;
• Agree with the treatment team recommendations.

When a discharge decision is made, the provider/treatment team documents the goals the patient has achieved, any anticipated needs for treatment and rehabilitation services, and readiness for participation in a different level care. The provider/treatment team assists patients with the transition to appropriate services and will ask providers to whom patients have been referred, to participate in transition planning, the provider(s) will meet with the patient and the receiving provider(s) if necessary to ensure a successful transition. MPC will not discharge a patient until the patient has made a successful transition.

If discharge or transfer is not successful, MPC may arrange for continuation of services.

For medical emergencies, dial 911.

In case of non-medical emergency after MPC’s office has closed, dial MPC’s main number (240-585-5142) and leave a message with the 24-hour answering service. A MPC member will call you back within one (1) hour.

For patients with commercial insurance and Medicare: Co-payments, coinsurance and/or deductibles are the responsibility of the patient or responsible party and are due at the time of service. It is the patient responsibility to obtain a written referral and authorization if the patient’s insurance requires the same.

Failure to obtain the referral and/or preauthorization may result in a lower or no payment from the insurance company.

For patients without insurance: MPC will obtain an initial authorization to cover the first two diagnostic appointments and an uninsured span if applicable. Self-pay patients are welcome if those patients do not qualify for such assistance.

In the event the patient submits payment by check and that check is returned for any reason by the bank, MPC may add $30.00 to the balance owed by the patient or responsible party.

Missed Appointments: Patients are responsible for keeping all scheduled appointments. If a patient is unable to keep an appointment, the patient is expected to contact MPC as soon as possible (24 hours in advance) to cancel the appointment. This allows MPC to offer an appointment time to another patient who may have an urgent need. Without advance notice, it is possible that the patient will be billed for a No-Show appointment ($75.00).

No statement by an employee or agent of MPC will contradict, void, or nullify this Agreement, nor shall the patient rely on any statements or opinions made by MPC that patient's insurance will pay the bill.

Payments: Unless other arrangements are approved by MPC in writing, the balance on your statement is due and payable when a statement is issued, and past due if payment is not received within 60 days after payment has been received by the insurance company.

Past due accounts: If an account becomes past due, MPC may take the steps necessary to collect this debt. If MPC has to refer an account to a collection agency and/or an attorney, the patient or responsible party agree to pay all of the collection costs that are incurred, including attorney fees and court costs, if applicable.

Waiver of confidentiality: If an account is submitted to an attorney and/or collection agency, if MPC has to litigate in court, or if a patient’s past due status is reported to a credit reporting agency, the fact that a patient received treatment and that the patient’s account is delinquent with MPC will become a matter of public record.

By signing below, I acknowledge that I have been provided the following documents for review.

1. Notice of privacy practices
2. Patient Rights
3. Grievance Procedures
4. Discharge/Transfer Procedures
5. Emergency Procedures
6. Outpatient Financial Agreement
7. Maryland Department of Health publication Advance Directive for Mental Health Treatment

Informed Consent to Treatment

By signing below, I acknowledge that I give my full consent to be evaluated and treated and do hereby seek and consent to take part in MPC's treatment programs.

I am aware that I might be asked to discuss personal aspects of my life that might be distressing to me, and I am also aware that I have the right to discuss only those topics that I am comfortable discussing.

I agree to work with MPC staff to develop and regularly review a treatment plan.

I understand that no promises have been made to me as to the results of treatment.

My signature below reflects my understanding and agreement with the statements above.

Confidentiality

MPC is obligated to protect your personal information. MPC staff is not allowed to share or disclose any of your personal information without your consent. However, there are some limits of confidentiality; if you are deemed in danger to yourself or others; MPC staff is obligated to take reasonable steps to help ensure safety. If your records are subpoenaed by a Court or legal authority, MPC might need to comply with the order from the court.

Please note, licensed providers are mandated reporters of abuse and neglect to the respective authorities. In the event you are admitted to a hospital or detained by legal authorities; you allow MPC to release information related to helping ensure the continuity of your care.

Please note that your treatment team and providers will communicate regarding your care to provide holistic and continuous care. All team members and providers will have access to your records in an effort to further ease of collaboration and increase effectiveness and expediency of treatment.

By signing below, I acknowledge that I understand and accept the limits of confidentiality.

Use of Information

In order to best serve your needs, MPC keeps records of your Protected Health Information (PHI). Your records are used to help treat you, obtain payment for your services, and to ensure compliance with our monitoring agencies. Your treating staff might record in writing statements that you make, symptoms you describe, medications you are on, and any information deemed pertinent to your treatment. To obtain payment for your services, staff might use and disclose your PHI to the State of Maryland's DHMH, CSA of Charles County, the State's ASO, Optum Maryland, Medicaid, Medicare, or to any other agency needed to process our billing claims for your services. The Core Service Agency and the Mental Health

Administration periodically audit charts to ensure MPC is in compliance with State regulations. Your chart may be selected to review.

By signing, I agree and consent to the use of patient PHI as described above.

By signing, I acknowledge, and agree to the terms and information listed above regarding Policy Receipt, Informed Consent to Treatment, Patient Rights, Confidentiality, and Use of Information.