I understand that if I choose not to use my insurance benefits (“self pay”) or if Great Lakes Psychological Assessment is not a participating provider with my insurance plan (“out of network”), I will pay in full, at the time of service, for all services rendered on my behalf. I understand that if Great Lakes Psychological Assessment is a participating provider (“In network”) I will pay the. copay at the time of service & Great Lakes Psychological Assessment will submit a claim to my insurance provider. I hereby give consent to Great Lakes Psychological Assessment to release any required health information to my health care insurance provider to assist in the processing of claims, including protected healthcare information in accordance with the Health Insurance Portability and Accountability Act (HIPPA). I also and acknowledge that I am responsible for any charges not covered by my health insurance. I understand that 24 hours notice of cancellation is required to avoid a $100 charge for missed appointments. I also understand that I may be charged a late fee if I arrive more than 15 minutes late to my appointment. I understand that missed appointment fees and late fees are not covered by insurance plans. In the event my account is sent to collections, I agree to pay for all charges incurred, court costs, interest, and reasonable attorney's fees. Your signature indicates that you have read and agree to the financial agreement.

(45 CFR 164.520(a) (42 CFR Part 2) Effective Date, February 1, 2016 THIS NOTICE DESCRIBES HOW MEDICAL/HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. If you have any questions about this notice, please contact the Great Lakes Psychological Assessment. WHO WILL FOLLOW THIS NOTICE. This notice describes our practices and that of, • Any health care professional authorized to enter information into your chart. • All departments and units of the Great Lakes Psychological Assessment. • Any member of a volunteer group we allow to help you at Great Lakes Psychological Assessment • All employees, staff and other personnel of Great Lakes Psychological Assessment. All these entities, sites and locations follow the terms of this notice. In addition, these entities, sites and locations may share medical/health information with each other for treatment, payment Great Lakes Assessment operations purposes described in this notice. OUR PLEDGE REGARDING MEDICAL /HEALTH INFORMATION. We understand that medical/health information about you and your health is personal. We are committed to protecting medical/health information about you. We create a record of the care and services you receive at Great Lakes Assessment. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applied to all of the records of your care generated by Great Lakes Assessment. Other health care rehabilitation facilities may have different policies or notices regarding use and disclosure of your medical/health information. This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical/health information. We are required by low to , • Make sure that medical/health information that identifies you is kept private; • Give you this notice of our legal duties and privacy practices with respect to medical/health information about you; and • Follow the terms of the notice that is currently in effect. HOW WE ARE REQUIRED BY LAW TO DISCLOSE MEDICAL/HELATH INFORMATION ABOUT YOU. • As Required by Law. We will disclose medical/health information about you when required to do so by federal, state or local law. • To Avert a Serious Threat to Health or Safety. We will use and disclose medical/health information about you when we have a “Duty to Warn/Report? Under state or federal law, because we believe that it is necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat. • Public Health Risks. We will disclose medical/health information about you for public health reporting required by federal or state law. These activities generally include the following, o To prevent or control disease, injury or disability; o To report births and deaths; o To report child abuse or neglect; o To report reactions to medications or problems with products; o To notify people or recalls of products they may be using; o To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; o To notify the appropriate government authority 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. • Health oversight Activities. We will disclose medical/health information as required by law to a health oversight agency for activities authorize by law. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws. • Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we will disclose medical/health information about you when properly ordered to do so by a court. • Law Enforcement. We will release medical/health information if asked to do so by a law enforcement official, and if permitted by law, o In response to a court order; o If required by state or federal law; o To identify or locate a suspect, fugitive, material witness, or missing person; o About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement; o About a death we believe may be the result of criminal conduct; o About criminal conduct at Great Lakes Psychological Assessment or associated facility; and o In emergency circumstances to report a crime; the location of the crime or victims, or the identity, description or location of the person who committed the crime. • Protective Services for the President and Others. We will disclose medical/health information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state, or conduct special investigations. HOW WE MAY USE AND DISCLOSE MEDICAL/HEALTH INFORMATION ABOUT YOU. The following categories describe different ways that we use and disclose medical/health information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use of disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories. • For Treatment. We may use medical/health information about you to provide you with medical/health treatment or services. We may disclose medical information about you to doctors, psychologists, nurses, social workers, therapists, technicians, medical students, or other Great Lakes Psychological Assessment personnel who are involved in taking care of you. We also may disclose medical/health information about you to people outside of Great Lakes Psychological Assessment, such as other health care providers involved in providing medical/health treatment for you and to people who may be involved in your medical/health car, such as family members, clergy or others we used to provide services that are part of your care. • For Payment. We may use and disclose medical/health information about you so that the treatment and services you receive at Great Lakes Psychological Assessment, or other health care providers from whom you receive treatment, may be billed to, and payment may be collected from, you, an insurance company or a third party. For example, we may need to give your health plan information about treatment you received at Great Lakes Psychological Assessment so your health plan will pay us or reimburse you for your treatment. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. • For Health Care Operations. We may use and disclose medical/health information about you for Great Lakes Assessment operations or to another health care provider or health plan, if you have a relationship with that health care provider or health plan. These uses and disclosures are necessary to operate the Great Lakes Psychological Assessment and make sure that all of our clients receive quality care. For example, we may use medical/health information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine medical/health information about many clients to decide what additional services Great Lakes Psychological Assessment should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, social workers, therapists, nurses, psychologists, technicians, medical students, and other personnel for review and learning purposes. We may combine the medical/health information we have with medical/health information from other health care providers to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of medical/health information so others may use it to study health care and health care delivery without learning who the specific clients are. • Appointment Reminders. We may use and disclose medical/health information to contact you as a reminder that you have an appointment for treatment or medical/health care at Great Lakes Assessment. • Treatment Alternatives. We may use and disclose medical/health information to tell you about or recommend possible treatment options or alternative that may be of interest to you. • Health-Related Benefits and Services. We may use and disclose medical/health information to tell you about health-related benefits or services that may be of interest to you. • Individuals Involved in Your Care or Payment for Your Care. We may release certain limited information about you to a friend or family member who is involve in your medical/health care. We may also give information to someone who helps pay for you care. We may tell your family or friends your condition. In addition, we may disclose medical/health information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location. • Research. Under certain circumstances, we may use and disclose medical/health information about you for research purposes. For example, a research project may involve comparing the health and recovery of all clients who received one medication to those who received another, for the same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of medical/health information, trying to balance the research needs with clients’ needs for privacy of their medical/health information. Before we use or disclose medical/health information for research, the project twill have been approved through this research approval process. However, we may disclose medical/health information about you to people preparing to conduct a research project, for example, to help them look for clients with specific medical/health needs, so long as the medical/health information they review does not leave Great Lakes Psychological Assessment. We may ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care. Special Situations • Organ and Tissue Donation. If you are an organ donor, we may release medical/health information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation. • Military and Veterans. If you are a member of the armed forces, we may release medical/health information about you as required by military command authorities. We may also release medical/health information about foreign military personnel to the appropriate foreign military authority. • Coroners, Medical Examiners and Funeral Directors. We may release medical/health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical/health information about clients of Great Lakes Assessment to funeral directors as necessary to carry out their duties. • National Security and Intelligence Activities. We may release medical/health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law. • Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical/health information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution. YOUR RIGHTS REGARDING MEDICAL/HEALTH INFORMATION ABOUT YOU. You have the following rights regarding medical/health information we maintain about you, • Right to Inspect and Copy. You have the right to inspect and copy medical/health information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes. To inspect and copy medical/health information that may be used to make decisions about you, you must submit your request in writing to Great Lakes Psychological Assessment. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with you request. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical/health information, under some circumstances you may request that the denial be reviewed. Another licensed health care professional chosen by the Great Lakes Assessment will review your request and denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review. • Right to Amend. If you feel that medical/health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the Great Lakes Psychological Assessment. To request an amendment, your request must be made in writing and submitted to Great Lakes Psychological Assessment. In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that, o was not created by us, unless the person or entity that created the information is no longer available to make the amendment; o is not part of the medical information kept by or for the hospital o is not part of the information which you would be permitted to inspect and copy; or o is accurate and complete. • Right to an Accounting of Disclosures. You have the right to request an “Accounting of Disclosures.” This is a list of the disclosures we made of medical/health information about you. Your “Accounting of Disclosures” will not include certain disclosures that are exempt from accounting requirements by federal or state law, including but not limited to disclosures made for treatment, payment, and health care operations and pursuant to an authorization. To request this list or accounting of disclosure, you must submit your request in writing to Great Lakes Psychological Assessment. Your request should indicate in which may not be longer than six years prior to the date of request. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12 month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. • Right to Request Restrictions. You have the right to request a restriction or limitation on the medical/health information we use or disclose about you for treatment, payment or health care operation. You also have the right to request a limit on the medical/health information we disclose about you to someone who is involved in your care or the payment for you care, like a family member or friend. Fro example, you could ask that we not use or disclose information about a specific treatment session you had. We are not required to agree to your request. If we do agree, we will comply with you request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing to Great Lakes Psychological Assessment. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse. • Right to Request Confidential Communications. You have the right to request that we communicate with you about medical/health matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to Great Lakes Psychological Assessment. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted. • Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. To obtain a paper copy of this notice, ask your treatment provider or the client services staff. You may also contact Great Lakes Psychological Assessment to request a paper copy. CHANGES TO THIS NOTICE. We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in each of our facilities. The notice will contain on the first page, the effective date. In addition, each time you register at or are admitted to Great Lakes Psychological Assessment for treatment or health care services as an inpatient or outpatient, we will offer you a copy of the current notice in effect. COMPLAINTS. If you believe your privacy rights have been violated, you may file a complaint with Great Lakes Assessment or with the Secretary of the Department of Health and Human Services. To file a complaint with Great Lakes Assessment, contact Great Lakes Psychological Assessment at 9010 DuPont Circle Dr, Suite 140, Fort Wayne, IN 46804. All complaints must be submitted in writing. You will not be penalized for filing a complaint. If you have any questions, please contact Great Lakes Psychological Assessment at (260) 570-4515. You may also contact Joint Commission at 1-800-994-6610 or by e-mail at complaint@jointcommission.org, or contact the Division of Mental Health and Addiction (DMHA) Consumer Service Line at 1-800-901-1133. You have the right to contact and consult with legal counsel. OTHER USES OF MEDICAL/HEALTH INFORMATION. Other uses and disclosures of medical/health information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical/health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical/health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosure we have already made with your permission, and that we are required to retain our records of the care that we provided to you. CONFIDENTIALITY OF ALCOHOL AND DRUG ABUSE CLIENT RECORDS. When a client is enrolled in Great Lakes Psychological Assessment substance abuse treatment program, the confidentiality of alcohol and drug abuse client records maintained by Great Lakes Psychological Assessment is protected by 42 CFR Part 2 Federal law and regulations. Generally, Great Lakes Psychological Assessment may not communicate to a person outside the program that a client attends the program, or disclose any information identifying a client as an alcohol or drug abuser UNLESS, • The client consents in writing; • The disclosure is allowed by a court order; or • The disclosure is made to medical personnel for research, audit, or program evaluation. Disclosure which are permitted without the client’s written consent include, • Internal communication between Great Lakes Psychological Assessment staff who have a need to know for continuity of treatment, billing purposes, etc.; • Qualified service organizations who provide services to the program, including but not limited to data processing, bill collection, medication dosage preparation, laboratory analyses, legal/medical/accounting services etc.; • Medical emergencies. Violation of the Federal 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 client either at the program or against any person who works for the program or about any threat to commit such a crime. Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported. CLIENT ACKNOWLEDGEMENTS / CONSENTS 1. I agree to be evaluated by a member of Great Lakes Psychological Assessment’s clinical staff. Following the evaluation, I will be asked to consent to specific treatment recommendations as stated in the treatment plan. 2. I understand these services are voluntary and that I may revoke consent at any time. 3. I understand that Great Lakes Assessment is comprised of a group of independent practitioners, who have no ownership interest in Great Lakes Assessment, and are each independently owned companies. I understand that each individual provider has been accepted by Great Lakes Assessment as an authorized practice to rent its facilities. 4. I have received a copy of my Rights and Responsibilities in regard to services being provided. Great Lakes Psychological Assessment's staff have reviewed and explained these rights to me and, when appropriate, to my family/advocate/representative. 5. I have received a copy of Great Lakes Psychological Assessment’s Notice of Privacy Practices. I acknowledge that the above statements and information have been explained and reviewed with me, and I understand the statements. My signature below indicates that the results of the assessment, treatment recommendation and proposed interventions have been explained to me. I voluntarily consent to participate in this plan of care. I am aware that similar services are available from other provider organizations and agencies. I choose to receive services through Great Lakes Psychological Assessment. Your Signature or Signature of Parent/Legal Guardian