NOTICE OF PRIVACY PRACTICES

Monaco & Associates Inc

4125 Gage Center Drive, Suite 204

Topeka, Kansas 66604

(785) 272-5501

Effective April 14, 2003

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW THIS NOTICE CAREFULLY.

In this notice we will tell you how we may use and disclose protected health information about you. Protected health information means any health information about you that could identify you (for example, your social security number). In the header above, this information is called medical information. In this notice, we will call protected health information just “health information”.

This notice will tell you about our privacy practices in accordance with the laws and will tell you about your rights and duties in regard to your health information. Also, it will describe how you can complain to us if you think we have violated your privacy rights.

We 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. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our Notice at any time. Any new Notice of Privacy Practices will be effective for health information that we maintain at that time. We will provide you with a copy of the revised Notice by posting a copy on our website, sending a copy to you in the mail upon your request and having a copy of our current Notice available in our office.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

For Treatment. Your health information may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing services and supports. This includes consultation with supervisors or other team members. We may share or disclose your health information with other health care providers so that the services you receive related to your support plan will be able to work together. We may refer you to other professionals for services we cannot provide to obtain new services for you. When we do this we need to tell them some things about you and your needs. These are some examples so that you can see how we use and disclose your health information for treatment.

For Payment. We may use and disclose health information about you so that we can receive payment for the services we provide to you. Examples of payment-related activities are billing a third party payor, such as Medicaid or your insurance company. We may need, for example, to provide the Medicaid program with information about the services we provide to you so that we will be reimbursed for those services. Also, we may need to provide the Medicaid program with information to ensure you are eligible for the medical assistance program.

For Health Care Operations. There are a few other ways we may use or disclose your health information for

what are called health care operations. For example, we may use your health information to see where we can make improvements in the services we provide. We may use the information to explore ways to more efficiently manage our business, for licensing or accreditation activities, or for our compliance program.

Appointment Reminders. We may use and disclose health information to reschedule or remind you of appointments or meetings regarding your services.

How We Will Contact You. If you want us to call or write to you only at your home or work or prefer some other way to reach you, we can usually arrange that. If you want to request that we communicate with you in a certain way or at a certain place, see “Right to Receive Confidential Communications” in this Notice. Unless you tell us otherwise, we may contact you either by telephone or by mail at either your home or work. At either location, we may leave messages for you on the answering machine or voice mail.

Treatment and Service Alternatives. We may use or disclose your health information to tell you about or suggest possible treatments or services that may be of interest to you.

Other Benefits and Services. We may use or disclose your health information to tell you about health related benefits that may be of interest to you.

Marketing Communications. We may use and disclose health information about you to communicate with you about a product or service to encourage you to purchase the product or service. This may be, for example, for your treatment, for case management, or to suggest alternative services or health care providers. We may communicate to you about products and services in face-to-face communication by us to you. We may also communicate about products or services in the form of a promotional gift of nominal value. All other use and disclosure of health information about you by us to communicate about a product or service or to encourage the purchase or use of a product or service will be done only with your written authorization.

REQUIRED BY LAW

Under the law, we must make disclosures of your health information to you upon your request (see “Right of Access to Inspect and Copy” in this Notice). In addition we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule.

WITHOUT AUTHORIZATION

Applicable law and ethical standards permit us to disclose information about you without your authorization only in a limited number of situations. The types of uses and disclosures that may be made without your authorization are those that are:

1.Required by Law, such as the mandatory reporting of child abuse or neglect or mandatory government agency

audits or investigations.

2. Required by Court Order

3. Necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the

public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or

persons reasonably able to prevent or lessen the threat, including the target of the threat.

Disclosures to family and others: We may disclose to a guardian/parent, personal representative, family member, or any other person identified by you, health information that is relevant to that person’s involvement with the supports and services you receive or payment for those services and supports. An example would be if there was a health emergency and we needed to notify those persons of your situation. If there is a family member or other relative that you do not want us to disclose health information about you to, please notify Jill Marks, Monaco & Associates Inc, 4125 Gage Center Drive, Suite 204, Topeka, Kansas, 66604 (785) 272-5501 or tell the Case Manager who is providing services to you.

Disaster Relief: We may use or disclose health information about you to a private or public organization authorized by law to assist in disaster relief efforts. For example, to coordinate with those entities in notifying a parent/guardian, close relative or other person identified by you of your circumstances in the event of a disaster.

Public Health Activities: We may disclose some of your health information to agencies, which investigate diseases or injuries for the purpose of preventing and controlling diseases. Or, one that is authorized to receive reports of child abuse and neglect.

Victims of Abuse, Neglect or Domestic Violence: We may disclose health information about you to a legally authorized government authority to receive reports of abuse, neglect or domestic violence if we believe you are a victim of abuse, neglect or domestic violence. This will occur to the extent the disclosure meets the following conditions. The disclosure is: a) required by law, b) agreed to by you or your personal representative, or c) authorized by law and we believe the disclosure is necessary to prevent serious harm to you or to other potential victims or d) if you are incapacitated and certain other conditions are met or a law enforcement or other public official represents that immediate enforcement activity depends on the disclosure.

Health Oversight Activities. We may disclose health information about you to a health agency for activities authorized by law, including licensing, investigations, or audits. These kinds of activities are needed for oversight of the health care system and entities subject to various government regulations.

Judicial and Administrative Proceedings. We may disclose health information about you in the course of a judicial or administrative proceeding in response to a court order. We may disclose health information about you in response to a subpoena or other legal process but only if efforts have been made to tell you about the request or to obtain an order protecting the information to be disclosed.

For Law Enforcement Purposes. We may disclose health information about you to a law enforcement official as required by law, in response to a court, grand jury or administrative order, subpoena or warrant. We may also disclose health information to identify or locate a suspect, material witness, missing person or fugitive or about an actual or suspected crime victim if that person agrees to the disclosure. In limited circumstances, if we are unable to obtain that person’s agreement the information may still be disclosed. We may also disclose health information to alert law enforcement officials to a death if we suspect the death may have resulted from criminal activity or to report a crime in emergency situations.

To Avert Serious Threat to Health or Safety. We may use or disclose protected health information about you if we believe the disclosure or use is necessary to prevent or lessen an imminent or serious threat to the health or safety of a person or the public. We may also release information if we believe it is necessary for law enforcement to apprehend or identify a person who admitted participation in a violent crime or who is an escapee from a correctional institution or from lawful custody.

For specific government functions. We may disclose the health information of military personnel and veterans to government benefit programs relating to eligibility and enrollment. We may disclose your health information to Worker’s Compensation and Disability programs, to correctional facilities if you are an inmate, and for national security reasons.

VERBAL PERMISSION

We may use or disclose your information to family members that are directly involved in your treatment with your verbal permission.

WITH AUTHORIZATION.

Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked. If we want to use your health information for any purpose besides the treatment, payment or health care operations or those we described above, we need your written permission. If you do authorize us to use or disclose your health information, you can revoke (cancel) that permission, in writing, at any time. Of course, we cannot take back any information we had already disclosed with your permission or that we had used in our office. To revoke an authorization, notify Jill Marks, Monaco & Associates Inc, 4125 Gage Center Drive, Suite 204, Topeka, Kansas, 66604 (785) 272-5501.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

You have the following rights regarding the health information we maintain about you. To exercise any of these rights, please submit your request in writing to: Jill Marks, Monaco & Associates Inc, 4125 Gage Center Drive, Suite 204, Topeka, Kansas 66604 (785) 272-5501

Right of Access to Inspect and Copy. You have the right, which may be restricted only in exceptional circumstances, to inspect and copy health information that may be used to make decisions about your care. Your right to inspect and copy health information will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you. We may charge a reasonable, cost-based fee for copies. We will act on your request within thirty (30) calendar days after we receive your request. If we deny the request, we will inform you of the reasons for the denial, how you can have the denial reviewed and how you may complain.

Right to Amend. If you feel that the health information we have about you is incorrect or incomplete,

you may ask us to amend the information although we are not required to agree to the amendment. We

will act on your request within 60 (sixty) calendar days after we receive your request.

Right to an Accounting of Disclosures. You have the right to request an accounting of certain of the disclosures that we make of your health information. This accounting may be for up to six years prior to the date on which you request the accounting but not before April 14, 2003. We may charge you a reasonable fee if you request more than one accounting in any 12-month period. We will act on your request within sixty (60) calendar days after we receive your request.

Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your health information for treatment, payment, or health care operations at any time. You also have the right to request that we restrict the uses or disclosures we make to a family member or any other person you identify or to public/private entities for disaster relief. For example, you could ask that we not disclose your information to your sister or brother. We are not required to agree to any requested restriction.

Right to Request Confidential Communication. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. For example, you may ask that we only contact you at home or by mail. You do not have to tell us why you are choosing this way of communicating confidential information. We may require an alternate method or address to contact you.

Right to a Copy of this Notice. You have the right to a paper copy of this notice. To obtain a paper copy of this notice, please contact Jill Marks, Monaco & Associates Inc. 4125 Gage Center Drive, Suite 204, Topeka, Kansas 66604 (785) 272-5501. Our Notice of Privacy Practices is posted on our web site. You may obtain a copy of our Notice of Privacy Practices over the Internet at our web site: www.monacoassociates.com.

COMPLAINTS

If you believe we have violated your privacy rights, you have the right to file a complaint in writing with us.

To file a complaint, contact Jill Marks, Monaco & Associates Inc, 4125 Gage Center Drive, Suite 204, Topeka, Kansas 66604 (785) 272-5501. You may complain to the Secretary of Health and Human Services at 200 Independence Avenue, S.W. Washington, D.C. 20201 or by calling (202) 619-0257.

You will not be retaliated against for filing a complaint.

If you have questions or problems:

If you need more information or have questions about the privacy practices described above, please contact:

Jill Marks at Monaco & Associates Inc.

The effective date of this Notice is April 14, 2003.