entity to defend itself in a legal action or other $roceeding brought by you' and (ii) a use or disclosure that is required

by or $ermitted by )ederal law NOTICE OF PRIVACY PRACTICES As required by the Health Insurance Portability and Accountability Act (HIPAA) of 1996, this notice describes how health information about you may be used and disclosed and how you can get access to this information Please review it carefully. WHO WILL FOLLOW THIS NOTICE !utgers Health "er#ices (hereafter referred to as !H") may only use your health information for treatment, $ayment, health care o$erations or research $ur$oses as described in the notice All of the em$loyees%staff, including& medical' counseling and $sychological ser#ices' $harmacy and other $ersonnel of !H" follow these $ri#acy $ractices A O!T THIS NOTICE (his notice will tell you about the ways we may disclose health information about you and will also describe your rights and certain obligations that we ha#e regarding the use and disclosure of your health information We are re"uire# $y law t%& 'a(e sure t)at )ealt) i*f%r+ati%* t)at i#e*tifies y%u is (e,t ,rivate .ive y%u t)is *%tice %f %ur le/al #uties a*# ,rivacy ,ractices wit) res,ect t% y%ur )ealt) i*f%r+ati%*a*# F%ll%w t)e ter+s %f t)e *%tice t)at is curre*tly i* effect. HOW WE 'AY !SE AN0 0ISCLOSE HEALTH INFOR'ATION A O!T YO! (he following categories describe different ways that we use and disclose health information )or each category of uses or disclosures we will e*$lain what we mean and gi#e you e*am$les +ot e#ery use or disclosure in a category will be listed Howe#er, all of the ways we are $ermitted to use and disclose information will fall within one or more of the categories F%r Treat+e*t& ,e may use health information about you to $ro#ide you with medical treatment or ser#ices ,e may disclose health information about you to& doctors, nurses, counselors, technicians, closely su$er#ised PA%-edical%+ursing students $artici$ating in clinical $rece$torshi$s, or other !H" $ersonnel, who are in#ol#ed in $ro#iding care for you )or e*am$le& If you are being seen in .ounseling and Psychological "er#ices at !H" and are recei#ing care by a medical $ro#ider at !H", health information may need to be shared to ma/e sure you are recei#ing a$$ro$riate integrated care 0e$artments within !H" may share health information about you in order to coordinate the different ser#ices you may need, such as $rescri$tions, lab wor/ and *1rays ,e may disclose health information about you to Pro#iders outside !H" who may be in#ol#ed in your health care (e g , a s$ecialist or surgeon) Psyc)%t)era,y N%tes& ,e will, in accordance to )ederal law, obtain your written authori2ation to release your $sychothera$y notes, if any, that are contained in your health records Howe#er, the entity may use or disclose your $sychothera$y notes for the following& (i) to carry out the following treatment, $ayment, or health care o$erations& (A) use by the originator of the $sychothera$y notes for treatment' (3) use or disclosure by the entity for its own training $rograms in which students, trainees, or $ractitioners in mental health learn under su$er#ision to $ractice or im$ro#e their s/ills in grou$, 4oint, family, or indi#idual counseling' or (.) use or disclosure by the F%r Pay+e*t& ,e may use and disclose health information about you so that we may bill for treatment and ser#ices you recei#e at !H" and can collect $ayment from you, an insurance com$any or another $arty )or e*am$le& ,e may need to gi#e information about ser#ices you recei#ed at !H" to your health insurance $lan so that the $lan will $ay us or reimburse you for the ser#ice ,e may tell your health insurance $lan about a treatment you are going to recei#e in order to obtain $rior a$$ro#al or to determine whether your $lan will co#er the treatment ,e may disclose information about you to other healthcare facilities for $ur$ose of $ayment as $ermitted by law ,e will only bill your bursar account if you as/ us' you will be required to sign the bursar form requesting this $rocess F%r Healt) Care O,erati%*& ,e may use and disclose health information about you for o$erations of !H" (hese uses and disclosures are necessary to run !H" and ma/e sure all of our $atients recei#e quality care )or e*am$le& ,e may use health information to e#aluate the $erformance of our staff in caring for you ,e may combine health information about many $atients to decide what additional ser#ices !H" should offer, what ser#ices are not needed, and effecti#eness of certain treatments ,e may disclose information to doctors, nurses, counselors, $harmacists, technicians, closely su$er#ised PA%-edical%+ursing%Psychology students $artici$ating in clinical $rece$torshi$s, and other !H" $ersonnel for educational $ur$oses A,,%i*t+e*t Re+i*#ers& ,e may use and disclose health information as a reminder that you ha#e an a$$ointment for treatment or ser#ices Service Alter*atives& ,e may use and disclose your health information in order to ma/e you aware of recommended ser#ice or $rogram alternati#es, which might be of interest to you I*#ivi#uals I*v%lve# i* Y%ur Su,,%rt %r Pay+e*t f%r Y%ur Care& ,e may release health information about you to any $erson identified by you on an authori2ed release form (his means that we will, upon your request only, disclose health information to a friend or family member who hel$s with your medical care, who hel$s $ay for your care or who you ha#e identified be notified in an emergency situation ,e will tell them only what they need to /now to hel$ you 5ou ha#e the right to say 6 *%7 to this release of information If you say 6no,7 we will *%t use or share your health information with your family or friends If you do not wish to share this information with your family and friends, $lease follow the $rocedures described in the !ight to !equest !estrictions section of this notice In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location Researc)& 8nder certain circumstances, we may use and disclose health information for research $ur$oses )or e*am$le, a research $ro4ect may in#ol#e com$aring the $rogress of all indi#iduals in#ol#ed in a certain ty$e of treatment $rogram com$ared to those in a different $rogram All research $ro4ects are sub4ect to a s$ecial a$$ro#al $rocess (his $rocess e#aluates a $ro$osed research $ro4ect and its use of health information 3efore we use or disclose health information for research, the $ro4ect

will ha#e been a$$ro#ed through this $rocess ,e will as/ for your s$ecific written authori2ation if your care is $art of a clinical research study or if the researcher will ha#e access to identifying information about you, such as& your name, address or other information that re#eals your identity As Re"uire# $y Law& ,e will disclose health information about you when required to do so by federal, state or local law T% Avert a Seri%us T)reat t% Healt) %r Safety& !H" may, consistent with a$$licable law and ethical standards, use or disclose $rotected health information if !H", in good faith, belie#es such use and disclosure is necessary to $re#ent or lessen a serious and imminent threat to the health or safety of a $erson or the $ublic and the disclosure is to a $erson or $ersons reasonably able to $re#ent or lessen the threat, including the target of the threat !H" must limit information that is used or disclosed and may only release the statement relating to the serious threat and the PHI related to the threat !H" is $resumed to ha#e acted in good faith in ma/ing such a disclosure, if the belief is based u$on actual /nowledge or in reliance on a credible re$resentation by a $erson with a$$arent /nowledge or authority Or/a* a*# Tissue 0%*ati%*& If you are an organ or tissue donor' we may release health information to organi2ations that handle organ $rocurement, organ, eye, or tissue trans$lantation, or organ donation ban/ 'ilitary a*# Vetera*s& If you are a member of the armed forces of the 8nited "tates or another country, we may release health information about you as required by the military command authorities W%r(ers1 C%+,e*sati%*& ,e may disclose health information about you for wor/ers9 com$ensation or similar $rograms (hese $rograms $ro#ide benefits for wor/1related in4uries or illness Pu$lic Healt) Ris(s& ,e may disclose your health information to authori2ed $ublic health or go#ernment officials as required by law for $ublic health acti#ities (hese acti#ities may include the following& (o the )ood and 0rug Administration ()0A) for $ur$oses related to the quality, safety or effecti#eness of an )0A1regulated $roduct or ser#ice (o $re#ent or control disease, in4ury or disability (o re$ort disease or in4ury (o re$ort births and deaths (o re$ort child abuse or neglect (o re$ort reactions to medications and food or $roblems with $roducts (o notify $eo$le of recalls or re$lacement of $roducts they may be using (o notify a $erson who may ha#e been e*$osed to a disease or may be at ris/ for contracting or s$reading a disease or condition (o notify the a$$ro$riate go#ernment authority if we belie#e a $atient has been the #ictim of abuse, neglect or domestic #iolence ,e will only ma/e this disclosure if you agree or when required or authori2ed by law Healt) Oversi/)t Activities& ,e may disclose health information to a health o#ersight agency for acti#ities authori2ed by law (hese o#ersight acti#ities include for e*am$le, audits, in#estigations, ins$ections, and licensure (hese acti#ities are necessary to monitor the health care system, go#ernment $rograms, and com$liance with ci#il rights laws Lawsuits a*# 0is,utes& If you are in#ol#ed in a lawsuit or a dis$ute, we may disclose health information about you in res$onse to a

court or administrati#e order ,e may also disclose health information about you in res$onse to a sub$oena, disco#ery request, or other legal demand by someone else in#ol#ed in the dis$ute, but only if efforts ha#e been made to tell you about the request or to obtain an order $rotecting the information requested Law E*f%rce+e*t& ,e may disclose health information if as/ed to do so by a law enforcement official& In res$onse to a court order, sub$oena, warrant, summons or similar $rocess (o identify or locate a missing $erson About the #ictim of a crime if, under certain circumstances, the $erson is unable to gi#e consent About a death we belie#e may be the result of criminal conduct About criminal conduct related to !H" o$erations In emergency circumstances to re$ort a crime' the locations of the crime or #ictims' or, to the e*tent $ermitted by law, the identity, descri$tion or location of the $erson who committed the crime (o authori2ed federal officials so they may $ro#ide $rotection for the President and other authori2ed $ersons or, to the e*tent $ermitted by law, to conduct s$ecial in#estigations C%r%*ers2 'e#ical E3a+i*ers a*# Fu*eral 0irect%rs& ,e may use and disclose health information to a coroner or medical e*aminer (his may be necessary, for e*am$le, to identify a deceased $erson or determine the cause of death ,e may also disclose health information to funeral directors so they can carry out their duties Nati%*al Security a*# I*telli/e*ce Activities& ,e may use and disclose health information about you to authori2ed federal officials for intelligence, counterintelligence, and other national security acti#ities authori2ed by law I* Le/al Cust%#y& If you are an inmate of a correctional institution or under custody of a law enforcement official, we may disclose health information about you to the correctional institution or law enforcement official Ot)er !ses %f Healt) I*f%r+ati%*& :ther uses and disclosures of health information not co#ered by this +otice or the laws that a$$ly to us will only be made with your written authori2ation 5ou can re#o/e such an authori2ation by writing to the Pri#acy :fficer, and such re#ocation will be effecti#e to the e*tent that we ha#e not already released the information $ursuant to the authori2ation or otherwise ta/en action based on the authori2ation YO!R RI.HTS RE.AR0IN. 'E0ICAL INFOR'ATION A O!T YO! 5ou ha#e the following rights regarding information we maintain about you&

health

Ri/)t t% I*s,ect a*# C%,y& 5ou ha#e the right to ins$ect and obtain co$ies of health information that may be used to ma/e decisions about your care 8sually, this includes medical and billing records (his right does not include& $sychothera$y notes' information com$iled for use in a legal $roceeding' certain information related to substance use, abuse or de$endence' or certain information sub4ect to the .linical ;aboratory Im$ro#ement Amendments of 19<< In order to ins$ect and obtain co$ies of your health information, you must submit your request in writing to .linical !ecords within the 0i#ision where care was $ro#ided If you request a co$y of the information, you will be charged a fee of =1 >>%$age for the cost of

co$ying, mailing, or other su$$lies associated with your request ,e may deny your request to ins$ect and co$y your records in certain limited circumstances If you are denied access to health information, you may request in writing, to the Pri#acy :fficer at !H", that the denial be re#iewed A licensed healthcare $rofessional will re#iew your request and the denial (he re#iewer will not be the $erson who denied your request ,e will com$ly with the outcome of the re#iew Ri/)t t% A+e*#& If you thin/ your health information is incorrectly recorded or incom$lete, you may as/ us to amend the information (he right to amend does not mean the right to obliterate or totally remo#e documentation from the record !ather it is an o$$ortunity to 6a$$end7 a statement of correction or clarification to the record and to /now that when the original statement is used or disclosed, the new 6correcti#e7 or 6clarified7 statement will accom$any any released co$ies 5ou ha#e the right to request an amendment for as long as the information is maintained by !H" (o request an amendment, your request must be made in writing and submitted to the Pri#acy :fficer at !H" In addition, you must gi#e a reason that su$$orts your request ,e may deny your request for an amendment if it is not in writing or does not include a reason to su$$ort the request In addition, we may deny your request if you as/ us to amend information that& ,as not created by us, unless the $erson or entity that created the information is no longer a#ailable to ma/e the amendment' Is not $art of the health information /e$t by or for !H"' Is not $art of the information that you would be $ermitted to ins$ect and co$y' or Is accurate and com$lete ,e will $ro#ide you with written notice of the action we ta/e in res$onse to your request for an amendment Ri/)t t% a* Acc%u*ti*/ %f 0iscl%sures& 5ou ha#e the right to request an 6accounting of disclosures7 (his is a list of certain disclosures that we made of your health information (he accounting will include& (he date of the disclosure' (he name of the entity or $erson who recei#ed the health information, and if /nown, the address of such entity or $erson' A brief descri$tion of the health information disclosed' or A brief statement of the $ur$ose of the disclosure or a co$y of the authori2ation ,e are not required to account for any disclosures made to you or for disclosures related to treatment, $ayment, healthcare o$erations, or made $ursuant to an authori2ation signed by you (o request an accounting of disclosures of your health care information, you must submit your request in writing to -edical !ecords within the 0i#ision where your care was $ro#ided or to the Pri#acy :fficer, as a$$ro$riate 5our request must state a time $eriod, which may not be longer than si* years and may not include dates before ?une <, @>1> 5our request should indicate in what form you want the list (for e*am$le, on $a$er or electronically) (he first list you request within a 1@1 month $eriod will be free )or additional lists, we will charge you =1 >>%$age for the cost of $ro#iding the list ,e will notify you of the costs in#ol#ed and you may choose to withdraw or modify your request at that time, before any costs are incurred Ri/)t t% Re"uest Restricti%*s& 5ou may ha#e the right to request a restriction or limitation on the health information we use or disclose about you for treatment, $ayment or health care o$erations 5ou also ha#e the right to request a limit on

the health information we disclose about you to someone who is in#ol#ed in your care or the $ayment for your care, such as a family member or friend (o request restrictions, you should ma/e a request in writing to the Pri#acy :fficer of !H" In your request you must $ro#ide the following& ,hat information you want to limit' ,hether you want to limit our use, disclosure or both' and (o whom you want limits to a$$ly' for e*am$le, disclosures to your $arents Howe#er, !H" is not required to agree to any request to restrict the 8se and 0isclosure of Protected Health Information, unless the disclosure is to a health $lan for $ur$oses of $ayment or health care o$erations and the PHI $ertains to a health care item or ser#ice for which the $ro#ider has been $aid out1of1$oc/et in full If we agree to your request, we will com$ly with your request unless the information is needed to $ro#ide you emergency treatment If you $aid out1of1$oc/et (or in other words, you ha#e requested that we not bill your health $lan) in full for a s$ecific item or ser#ice, you ha#e the right to as/ that your health information with res$ect to that item or ser#ice not be disclosed to your health $lan for $ur$oses of $ayment or health care o$erations, and we will honor that request Ri/)t t% Re"uest C%*fi#e*tial C%++u*icati%*s& 5ou ha#e the right to request that we communicate with you about health matters in a certain way or at a certain location )or e*am$le, you can as/ that we only contact you at wor/, by mail or #ia e1mail (o request confidential communication, you must ma/e your request in writing to .linical !ecords within the 0i#ision where your care was $ro#ided 5our request must s$ecify how or where you wish to be contacted ,e will not as/ you the reason for your request ,e will attem$t to accommodate reasonable requests Ri/)t t% a Pa,er C%,y %f N%tice& 5ou ha#e a right to a $a$er co$y of this +otice 5ou may as/ us to gi#e you a co$y of this notice at any time A#en if you ha#e agreed to recei#e this notice electronically, you are still entitled to a $a$er co$y of this notice (o obtain a $a$er co$y of this notice you can contact -edical !ecords within the 0i#ision where your care was $ro#ided Sale %f Y%ur Healt) I*f%r+ati%* (he sale of your health information without authori2ation is $rohibited 8nder )ederal law, certain uses and disclosures are not considered a sale of your information, including, but not limited to, disclosures for treatment, $ayment, for $ublic health $ur$oses, for the sale of $art or all of the entity, to any 3usiness Associate for ser#ices rendered on our behalf, and as otherwise $ermitted or required by law In addition, the disclosure of your health information for research $ur$oses or for any other disclosure $ermitted by law will not be considered a $rohibited disclosure if the only reimbursement recei#ed is a 6reasonable, cost1based fee7 to co#er the cost to $re$are and transmit your health information and as may otherwise be $ermitted under )ederal and "tate law If an authori2ation is obtained from you to disclose your health information in connection with a sale of your health information, the authori2ation must state that the disclosure will result in remuneration (meaning that the entity will recei#e $ayment for disclosure of your health information and any other requirements of law) 'ar(eti*/ ,e will, in accordance to )ederal law, obtain your written authori2ation to use or disclose your health information for mar/eting $ur$oses including all treatment and health care o$erations communications where we recei#e financial remuneration (meaning that

the entity recei#es direct or indirect $ayment from a third $arty whose $roduct or ser#ice is being mar/eted) unless such mar/eting is& (i) face to face mar/eting communications' (ii) $romotional gifts of nominal #alue regardless of whether they are subsidi2ed' (iii) 6refill reminders7, so as long as the remuneration for ma/ing such communications are 6reasonably related to our costs7 for ma/ing such communications' and (iii) any other acti#ity that does not require an authori2ation under )ederal and "tate law CHAN.ES TO THIS NOTICE ,e reser#e the right to change this +otice ,e reser#e the right to ma/e the re#ised or changed +otice effecti#e for health information about you that we already ha#e, as well as any information we recei#e in the future (he current +otice in effect at any time will be $osted on our web site at htt$&%%health rutgers edu and will also be a#ailable at all !H" $ractice locations including health centers and counseling and $sychological ser#ice locations Ri/)t t% Receive N%tificati%* %f a reac) ,e are required to notify you following disco#ery of a breach of your unsecured health information CO'PLAINTS If you belie#e your $ri#acy rights ha#e been #iolated, you may file a com$laint with the Pri#acy :fficer of !H" or with the "ecretary of the 8" 0e$artment of Health and Human "er#ices (o file a com$laint with !H" call or write to the Pri#acy :fficer at the address listed at the end of this +otice 5ou will not be $enali2ed for filing a com$laint 4!ESTIONS If you ha#e any questions about this Pri#acy +otice contact&

Rut/ers Healt) Services Privacy Officer Hurta#% Healt) Ce*ter 55 is)%, Place New ru*swic(2 N6 78975:5587 8;8:9<=:97;< EFFECTIVE 0ATE& Se,te+$er =<2 =75<