OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 04/14/2003, and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms or our Notice effective for all health information that we maintain, including health information we created or
received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment and healthcare operations. For example:

Treatment:
We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.

Payment:
We may use and disclose your health information to obtain payment for services we provide to you.

Healthcare Operations:
We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Your Authorization:
In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice

To Your Family and Friends:
We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.

Persons Involved in Care:
We may use or disclose health information to notify, or assist in the notification of (including identifying or location) a family member, your personal
representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

Marketing Health-Related Services:
We will not use your health information for marketing communications without your written authorization.

Required by Law:
We may use or disclose your health information when we are required to do so by law.

Abuse or Neglect:
We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

National Security:
We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized
federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement officials having lawful custody of protected health information of inmate or patient under certain circumstances.

Appointment Reminders:
We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters.

QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

PATIENT RIGHTS

Access:
You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.)

Disclosure Accounting:
You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

Restriction:
You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).

Alternative Communication:
You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. (You must
make your request in writing.) Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

Amendment:
You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be
amended.) We may deny your request under certain circumstances.

Electronic Notice:
If you receive this Notice on our Web sites or by electronic mail (e-mail), you are entitled to receive this Notice in written form

Contact Officer:
David Grove, Ph.D. Compass Clinical Associates, PLLC
Telephone (515) 412-5112
Address: 2500 82nd Place – Urbandale, Iowa – 50322

Beth Frettim, COO, Guided Ascent, LLC
Telephone (515) 412-5112
Address: 2400 82nd Place – Urbandale, Iowa – 50322

• The client has the right to be treated with dignity and respect.

• The client has the right to fair treatment. This is regardless of their race, religion, gender, ethnicity, age, disability, or source of payment.

• The client has the right to have their treatment and other member information kept private.

• Only in an emergency, or if required by law, can records be released without member permission.

• The client has the right to information from staff/providers in a language they can understand.

• The client has the right to an easy-to-understand explanation of their condition and treatment.

• The client has the right to know all about their treatment choices. This would mean no matter of cost or if they are covered or not.

• The client has the right to get information about services and role in the treatment process.

• The client has the right to information about providers.

• The client has the right to know the clinical guidelines used in providing and/or managing their care.

• The client has the right to provide input on policies and procedures.

• The client has the right to know about the complaint, grievance and appeal process.

• The client has the right to know about state and federal laws that relate to their rights and responsibilities.

• The client has the right to know of their rights and responsibilities in the treatment plan.

• The client has the right to share in the formation of their plan of care.

• The client has the responsibility to give providers information they need. This is so they can deliver the best possible care.

• The client has the responsibility to let their provider know when the treatment plan no longer works for them.

• The client has the responsibility to follow their medication plan. They must tell their provider about medical changes, including medication given to them by other providers.

• The client has the responsibility to treat those giving them care with dignity and respect.

• The client should not take actions that could harm the lives of employees, providers, or other clients.

• The client has the responsibility to keep their appointments. The client should call their providers as soon as possible if they need to cancel visits.

• The client has the responsibility to ask their providers questions about their care. This is so they can understand their care and their role in that care.

• The client has the responsibility to let their provider know about problems with paying fees.

• The client has the responsibility to follow the plans and instructions for their care. The care is to be agreed upon by the member and the provider.

Authorization for Services
Our clinicians participate with various HMOs, PPOs and other managed-care organization. Some of these plans require preauthorization before the first visit. I understand it is my responsibility to obtain this authorization. Mental health benefits prior to my visit. If I have not done this prior to my visit and/or treatment is not a payable benefit, I will be responsible for the full payment at the time of service. Further, if my insurance carrier determines that the services I receive are not medically necessary, I will be responsible for the full payment of the bill.

Payment at the Time of Service
I will make payment in full at the time of each visit unless other arrangements have been made in advance. Insurance will be filed by the office at no charge and I will make any deductible, co-payments, or non-covered service payments at the time of service. The parent/guardian signing intake documentation is considered the responsible party for payment. All self-pay contracts will be paid at the time of service. I understand there will be a $30.00 fee for any returned check.

Canceled or Missed Appointments
I understand that when scheduling an appointment, I am reserving professional time in advance. It is my responsibility to keep scheduled appointments. If unable to keep an appointment, I agree to provide a minimum or 24- hour notice during business hours. I acknowledge that a pattern of missed appointments constitutes grounds for termination of services. I will pay a minimum of $75.00 for all missed appointments and appointments cancelled without a 24-hour notice. I acknowledge that my insurance plan will not cover these fees.

Requests for Records
I agree to pay for any copies of records sent to other facilities, providers, or insurance companies regarding my care (minimum $35.00). I also agree to pay for any reports or letters requested by or sent to a third party. The charge for review and completion of medical forms is $20.00 and letters is $15.00. These fees will be billed to the patient account and should be paid in a timely manner.

Court-Related Work
If my clinician is called upon to appear I court, testify in court, or prepare reports for the court related to services received, I agree to pay for all such services.

I have received a copy of this document and assign any insurance benefits to be payable to Compass Clinical Associates, PLLC and Guided Ascent, LLC.

I understand and agree to the following:

• Medication(s) for the management of my medical condition will be provided as long as I follow the rules/terms/conditions of this agreement. Failure to comply will result in the discontinuation of the medication(s) and/or termination from my provider’s care.

• I will use the medication(s) exactly as prescribed by my provider.

• I agree to submit to urine or oral fluid drug screens to detect the use of illegal substances, non-prescribed, and prescribed medications at any time and without 24-hour notice as ordered by my provider. I agree to the associated charges for the drug screens through the third-party provider, Millennium Health.

• I will disclose to my provider all other medications I am taking or that are prescribed to me and disclose to any other provider all medications that are prescribed to me from my provider.

• I agree to not obtain any other controlled medication without consulting with my provider. In the event of emergencies, I will notify my provider within 3 business days of any controlled drug I have obtained from urgent care, emergency departments, etc.

• I understand my provider will routinely access the Prescription Monitoring Program (PMP) to confirm controlled prescription medications I have purchased and which pharmacy they were purchased from.

• I am aware these drugs may lead to physical dependence and/or addiction and I will report any adverse side effects I experience from the controlled medication(s) prescribed to me including, but not limited to: drowsiness, unclear thinking, dizziness, slurred speech, and slowed reflexes.

• I agree to keep all scheduled appointments as requested by my provider and understand failure to do so may result in the ordering of a tapering schedule for my controlled substance.

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For Female Patients only:

• I understand that if I were to become pregnant, I am required to tell my provider immediately and understand this may result in tapering my controlled medications for the safety of the fetus.