NOTICE OF PRIVACY PRACTICES

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.

OUR PRIVACY POLICY

Drink-Less and its team members are committed to providing you with quality treatment. An important part of that commitment is protecting your health information according to applicable law. This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

OUR DUTIES

We are required by law to maintain the privacy of your PHI; provide you with notice of our legal duties and privacy practices with respect to your PHI; and to notify you following unauthorized release of PHI related to you. We are required to abide by the terms of this Notice of Privacy Practices. This Notice of Privacy Practices is effective as of the date listed on this Notice and will remain in effect until it is revised. We are required to modify this Notice of Privacy Practices when there are material changes to your rights, our duties, or other practices contained herein.

We reserve the right to change our privacy policy and practices and the terms of this Notice of Privacy Practices, consistent with applicable law and our current business processes, at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. Notification of revisions of this Notice of Privacy Practices will be available on premises as well as upon request.

We support and value your right to privacy and are committed to maintaining reasonable and appropriate safeguards for your PHI.

CONFIDENTIALITY OF ALCOHOL TREATMENT RECORDS

The confidentiality of alcohol patient records maintained by us is protected by Federal law and regulations. Generally, we may not say to a person outside the clinic that you are a patient of the clinic, or disclose any information identifying you unless:

1. ] (i) the patient consents in writing;

2. (ii) the disclosure is required by court order;

3. (iii) the disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation.

4. (iv) the disclosure is made to the Secretary of the Department of Health and Human Services to investigate our compliance with HIPAA.

See 42 U.S.C. 290dd-3 and 42 U.S.C. 290ee-3 for Federal laws and 42 CFR part 2 for Federal regulations.

USES AND DISCLOSURES

Your protected health information may be used and disclosed by our organization, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to collect payment, to support the operation of the organization, and any other use required by law.

Treatment: We may use medical information about you to provide you with medical treatment. We may share your medical information with Drink-Less management, providers, and staff who are involved in taking care of you, or provide services to you.

Payment and Healthcare Operations: We may use or disclose, as‐needed, your protected health information in order to support the business activities of our organization. These activities include, but are not limited to, payment collection, quality assessment activities, employee review activities, and conducting or arranging for other business activities. For example, we may contact you regarding the status of your appointments or payments. We may also call you by name while you are on premises.

We may use or disclose your protected health information in the following situations without your authorization: as Required By Law, Public Health issues as required by law, Communicable Diseases, Health Oversight, Abuse or Neglect, Food and Drug Administration requirements, Legal Proceedings, Law Enforcement, Criminal Activity, Military Activity, National Security, and Workers’ Compensation.

Other Permitted and Required Uses and Disclosures Will Be Made Only with Your Consent, Authorization or Opportunity to Object, unless required by law.

You may revoke this authorization, at any time, in writing, except to the extent that your physician or this organization has taken an action in reliance on the use or disclosure indicated in the authorization.

YOUR RIGHTS

All requests to exercise the following rights must be in writing. We will follow written policies to handle requests, and we will notify you of our decision or actions and your rights. Contact Drink-Less management using the contact information at the end of this Notice for more information or to obtain request forms.

Access to Medical Information: You have the right to access, inspect and obtain a copy of your PHI for as long as we maintain it as required by law. This right may be restricted only in certain limited circumstances as dictated by applicable law. In addition, we will transmit information from your medical file directly to a person or entity of your choosing, if the request is made in writing and you sign a release authorization.

We may charge a fee for the costs of copying, mailing, and other supplies associated with your request.

Request for a Restrictions: You have the right to ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may

be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.

Drink-Less is not required to agree to a restriction that you may request. If we believe, in our professional judgement, that it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional.

Amendment: You may request that we amend certain portions of your medical information if you believe that it is incorrect or incomplete. We may require you to give a reason to support your request. We are not required to make all requested amendments, but we will give each request careful consideration and will respond within 60 days of the request. We will deny a request for amendment if the information:

· Was not created by us, unless the person or entity that created the information is no longer available to make the amendment.

· Is not part of the medical information kept by Drink-Less

· Is not part of the information which you would be permitted to inspect or copy; or

· Is accurate and complete.

Accounting: You have the right to receive a list of certain disclosures of your medical information made by us. An accounting from paper records will not include disclosures for treatment, payment or health care operations.

Paper Notice: You are entitled to receive a written copy of this Notice at any time.

Complaints: If you believe your privacy rights have been violated, you may file a complaint with Drink-Less using the contact information at the end of this Notice. You may also submit a complaint to the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing. You will not be penalized or retaliated against for filing a complaint.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any questions about form, please ask to speak with Drink-Less management in person or by phone at 401-346-1599.

We welcome your comments: Please feel free to call us if you have any questions about how we protect your privacy. Our goal is always to provide you with the highest quality services.

Contact Information

Drink-Less

678 Park Avenue

Cranston, RI 02910

Attn: Management