It is the policy of Tailored Support Services to actively participate with other service providers in meeting the needs of individuals. It is our policy to maintain open communication with other providers, guardians and WSC’s to ensure a smooth transition into and out of our programs. This agency will provide all information necessary to assist the new provider in following the plan of care in order to meet the needs of the individual.

It is the policy of Tailored Support Services to provide tangible materials with regards to consumer bill of rights and due process. Agency personnel will review the materials with the consumer on an annual basis and entertain questions that the consumer might have. The agency representative will als o review the Workbook for Making Informed Choices to enhance decision making skills. These will be reviewed with each individual, each quarter. A discussion will occur pertaining to rights – what rights are of most concern and or importance to the individual, and whether his/her rights and choices have been violated or restricted. Attachments: • APD The Bill of Rights for Persons Who Are Developmentally Disabled • The Council on Quality Leadership choices and rights workbook

It is Tailored Support Services policy to ensure each employee and or volunteer of any program or service we provide comply with the Florida Statue Chapter 393.13 Bill of Rights of Persons with Developmental Disabilities. Individuals will be educated and advised of these rights on a continuous and ongoing basis through the service duration. Bill of Rights is as Follows: 1. The right to dignity, privacy, and humane care. 2. The right to religious freedom and practice. 3. The right to receive services within available sources, which protects the personal liberty of the individual and which are provided in the least restrictive conditions necessary to achieve the purpose of treatment. 4. The right to participate in an appropriate program of quality education and training services. 5. The right to social interaction and to participate in community activities. 6. The right to physical exercise and recreational activities. 7. The right to be free from harm, including unnecessary physical, chemical, or mechanical restraints, isolation, excessive mediation, abuse, and neglect. 8. The right to consent to or refuse treatment, subject to guardianship provisions. 9. No person having a developmental disability shall be excluded from participation in ordained benefits of or be subject to discrimination under any program or activity which receives public funds. 10. No person with a developmental disability shall be denied the right to vote in a public election. 11. The right to communication. 12. The right to possession and use of his/her own clothing and personal effects. 13. Each individual will receive prompt and appropriate medical treatment and care for physical and mental ailments and for the preventions of any illness or disability. 14. Each individual shall have access to individual storage space for private use. 15. No individual shall receive a treatment program to eliminate bizarre or unusual behavior without first being examined by a physician to determine if there is any organic cause for these behaviors. 16. Each individual in work programs, which require compliance with federal wage and hour laws, shall be provided the minimum wage protection and compensation for labor in accordance with the federal wage per hour regulations. 17. Each individual shall have a central record. The record shall include admission information, historical summaries, a summary of the individual's present condition , and all other required information under the regulations.

THIS NOTICE DESCRIBES HOW THE PROVIDER WILL USE PHI AND PROTECT THE HEALTH, SAFETY, AND WELL BEING OF THE RECIPENTS SERVED AND HOW YOU CAN GET ACCESS-T0 HER/"HIS INFORMATION. PLEASE REVIEW IT CAREFULLY. If you have and questions about this Notice, please contact our Privacy Officer Natalia McCluster This Notice of Privacy Practices describes how we may use and disclose your protected health information 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 or condition and related health care services. We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices. You may request a revised version by accessing our website or calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment. Uses and Disclosure s of Protected Health Information Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office who is involved in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of your physician's practice. Following are examples of the types of uses and disclosures of your protected health information that your physician's office is permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office. Treatment We will use and disclose your protected health information to provide, coordinate or manage your health care and any related services. This includes the coordination or management of your health care with another provider. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. We will also disclose protected health information to other physicians who may be treating you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. In addition, we may disclose your protected health information from time to time to another physician or health care provide r (e.g., a specialist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your health care diagnosis or treatment to your physician. Payment Your protected health information will be used and disclosed, as needed, to obtain payment for your health care services provided by us or by another provider. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services, w e recommend for you such as: making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity and undertaking utilization review activities. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission. Health Care Operations We may use or disclose, as needed, your protected health information in order to support the business activities of your physician's practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, fundraising activities, and conducting or arranging for other business activities. We will share your protected health information -with third party, "business associates" that perform various activities (for examples, billing or transcription services) for our practice. Whenever an arrangement between our office and a business associate involves the use of disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information. We may use or disclose you r protected health information as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. You may contact our Privacy Officer to request that these materials not be sent to you. We may use or disclose your demographic information and the dates that you received treatment from your physician, as necessary, in order to contact you for fundraising activities supported by our office. If you do not want to receive these materials, please contact our Privacy Officer and request that these fundraising materials not be sent to you or any OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES THAT MAY BE MADE WITHOUT YOUR AUTHORIZATION OR OPPORTUNITY TO AGREE OR OBJECT. We may use or disclose your protected health information in the following -situations without your authorization or providing you the opportunity to agree or object. These situations include: Required by Law We may use or disclose your protected health information to the extent that the use of disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, if required by law, of any such use s or disclosures. Public Health We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. For example, disclosure may be made for the purpose of preventing or controlling, disease, injury or disability. Communication Disease We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or sp reading the disease or condition. Health Oversight We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws. Abuse Exploitation or Neglect We may disclose your protected health information to a public health authority that is authorized by law to receive reports of abuse, exploitation, or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglects or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws. Legal Proceedings We may disclose protected health information in the course of any judicial or administrative proceeding, in response to and order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), or in certain conditions in response to a subpoena, discovery request or other lawful process. Law Enforcement We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes and other wise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of our practice, and (6) medical emergency (not on our practice premises) and it is likely that a crime has occurred. Coroners, Funeral Directors, and Organ Donation We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purpose. Criminal Activity Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual. Workers' Compensation We may disclose your protected health information as authorized to comply with workers' compensation laws and other similar legally established programs. Uses and Disclosures of Protected Health Information Based upon Your Written Authorization Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization in writing at any time. If you revoke your authorization, we will no longer use or disclose your protected health information for the reasons covered by your written authorization. Please understand that we are unable to take back any disclosures already made with your authorization. Other Permitted and Required Uses and Disclosures That Require Providing You the Opportunity to Agree or Object. We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use of disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then your physician may, using professional judgment, determine whether the disclosure is in your best interest. Other Involved in Your Health Care or Payment for Care Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person's involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest base on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representatives, or any other person that responsible for your care of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your healthcare. Your Rights Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights. You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you for as long as we maintain the protected health information. You may obtain your medical record that contains medical and billing records and any other records that your physician and the practice use for making decisions about you. A permitted by federal or state law, we may charge you a reasonable copy fee for a copy of your records. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information complied in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and laboratory results that are subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Officer if you have questions about access to your medical record. You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment, or health care 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 No tice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to a restriction that you may request. If your physician does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your physician. You may request a restriction by making a request in writing and submitted to the privacy officer. You have the right to request to receive confidential communication from us by alternative means or at an alternative location. We will accommodate reasonable request. We may also condition this accommodation by asking you for information as to how payment will be handed or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Officer. You may have the right to have your physician amend your protected health information. This means you may request an amendment of protected health information about you in a designated record set for so long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Prepare contact our Privacy Officer if you have questions, about amending your medical record. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you if you authorized us to make the disclosure, for a facility directory, to family members or friends involved in your care, or for notification purposes, for national security or intelligence, to law enforcement (as provided in the privacy rule) or correctional facilities, as part of a limited data set disclosure. You have the right to receive specific information regarding these disclosures that occur after April 14, 2003. The right to receive this information is subject to certain exceptions, restrictions, and limitations. You have the right to obtain a paper copy of this notice from us. Upon request, even if you have agreed to accept this notice electronically. Complaints You may complain to us or to the local office of the Agency for Person with Disabilities if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Officer of your complaint. We will not retaliate against you for filing a complaint. You may contact our Privacy Officer using the information below for further information about the complaint process. Natalia McCluster, Privacy Officer Phone: (833)659-6989 Email: Compliance@tailoredsvcs.com

Tailored Support Services Administrators and its staff utilize multiple methods of communication and documentation completion options. Your preference is always a priority.

• Access, use or modify protected health information only for the purposes of performing my official duties. • Never access or use protected health information out of curiosity, or for personal interest or advantage. • Never show, information, or disclose protected health information to or with anyone who does not have the legal authority. • Never retaliate, coerce, threaten, intimidate, or discriminate against or take other retaliatory actions against individuals or others who file complaints or participate in investigations or compliance reviews. • Never remove protected health information from the work area without authorization. • Never share passwords with anyone or store passwords in a location accessible to unauthorized persons. • Always store protected health information in a place physically secure from access by unauthorized persons. • Dispose of protected health information by utilizing an approved method of destruction, which includes shredding, or witnessed destruction. I will not dispose of such information in wastebaskets or recycle bins. • I understand that penalties for violating one of the above limitations may include disciplinary action, up to an including dismissal • There are additional confidentiality requirements for the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Annual approved DCF online training is required.

I certify that I have been informed of rules of privacy information sharing as stipulated under HIPPA and adhered to this provider by signing this agreement. I understand that no information will be disseminated without prior consent from me and/or my guardian that is not outlined in this agreement. Only designated persons and professionals will have access to my personal information.

The grievance procedures of Tailored Support Services have been explained to me on this date. I have also been furnished with a copy of the grievance policy and process. I understand that if I have a problem that I am unable to resolve, it is my responsibility to contact Natalia McCluster, Owner/Operator of Tailored Support Services. If I am unable to write my own grievance, I understand that I can request reasonable accommodation which will allow for another person to assist me in filing my grievance. I understand, that if this grievance is not resolved within 30 days, I am able to seek further assistance from my waiver support coordinator to assist with a resolution.

This notice is to informed you, the individual being served by our agency and your guardian if applicable that you have the right to utilize the Abuse Hotline. The following information below is being provided to assist you with reporting abuse. THREE WAYS TO MAKE A REPORT • TELEPHONE: 1-800-96ABUSE/ 1-800-962-2973 TDD: (TELEPHONE DEVICE FOR THE DEAF) 1-800-453-5145 • FAX: A written report with your name and contact telephone number may be faxed to 1-800-914-0004 • VOICE MAIL MESSAGE: When lines are busy, and you are unable to wait, you may leave the report information in a voicemail box. It is extremely difficult for hotline counselors to attempt callbacks, so IT IS ESSENTIAL THAT YOU LISTEN CAREFULLY AND LEAVE COMPLETE AND ACCURATE INFORMATION REQUESTED OR A REPORT MAY NOT BE TAKEN. The system will allow 5 minutes. 1-800-770-0953

By typing my name below, I hereby grant permission to agency representatives of Tailored Support Services to transport me, or my ward, for the purpose of appointments or activities deemed necessary by the professional direct care personnel to be an important part of service delivery while receiving services through this program. I will not hold Tailored Support Services, contractors or volunteers responsible for any unforeseen traffic incidents or interruptions in transportation should they arise. I understand that transportation is an important part of my care. All representatives of Tailored Support Services will provide transportation in a vehicle that is considered safe and accommodating to the needs and comfort of the individual. All traffic laws will be abided by, which include use of a seat belt for all passengers while the vehicle is in motion. A record of traffic violations that have led to suspension, revocation or a conditional license will be obtained and filed accordingly. Individuals will not be transported by anyone without a valid driver’s license, proper registration and the district required minimum vehicle insurance policy.

By typing my name below, I do hereby give my consent to Tailored Support Services to use photographs and/or audio/video recordings taken during the course of their services for publicity, promotional and/or educational purposes, including Tailored Support Services publications or presentations, or broadcast via newspaper, internet or other media sources used for these purposes. I may, at any time, withdraw my consent for future use of photograph’s and/or audio video recordings with the understanding that such withdrawal of consent does not constitute removal from any previously produced print or digital material. I further agree that all photographs, audio/video recordings, and the materials produced using these items are and will remain the sole property of Tailored Support Services. Tailored Support Services will not distribute, sell, or otherwise transfer your photographs and/or audio/video recording to other parties. Having read the statements above with full knowledge and understanding, I consent to the above terms and waive all claims for compensation for use or for damages.

Please enter the information of the individual that will be receiving services

The following is the preferred schedule initially requested by you, the consumer and or guardian:

Tailored Support Services assign staff according to availability of the initial request determined during the interview held prior to the agency being hired by you (consumer or guardian). While we do support person centered services, we ask that any schedule changes be requested at least 7 days in advance to allow proper rescheduling of the care staff. Please know and understand that this agency will render services to the individual who we are being hired to render services to only and in accordance with the individuals Support Plan within the frequency not to exceed the authorized services delivery support authorization. The following are reasons service schedules may change without advance notice: The individual cancels due to illness, incidents, emergencies, or other matters The individual refuse services Due to unforeseen circumstances such as staff illness, incidents, and emergencies Support Authorization issues preventing provider to bill for rendered services *Other reasons not listed may also be considered by this agency and or you the consumer and or guardian. All schedule changes with the exception of the reasons listed above, should be requested as soon as possible via phone and will be considered official once confirmed and a signed schedule change acknowledgement form is completed.

By typing my name below I, the recipient receiving Florida HCBS iBudget Waiver Services and or my guardian, agree to have employees and the sub-contractors of Tailored Support Services render services to me at the frequency outlined in the state approved service authorization. I understand, the services provided to me are delivered from the sub-contractor in a person-centered manner. The activities, skills training, routine, personal needs, choices, and preferences are the primary focal point of service delivery. Additionally, my goals listed in my annual individual support plan have been developed by myself, with assistance from both my paid supports and natural supports when applicable. The sub-contractor and myself have established a schedule that he/she and I have mutually agreed upon based on my needs and availability. I attest, that I have reviewed the “Consumer Contract and Policies” (Appendix 2) which outlines the following: Agency Summary Program Scope Intake/Discharge/Termination (Transitioning) Schedule Key Assumptions Transportation Medical Treatment Due Process Grievance Processes Notice of Privacy Practices HIPPA I understand, I have the right to choose who I hire to perform work for me. Moreover, I understand I may terminate this contract at any time without cause.