NOTE: If you are experiencing a medical or psychiatric emergency do not fill out this form. Instead dial 911 or contact your primary medical care provider at once.

*Check the boxes that most accurately describe your race:

Person financially responsible for bill after insurance payment is received (complete only if patient is not financially responsible)

The undersigned (whether he/she signs as the agent of the patient or as patient him/herself) that in consideration of services rendered to the patient, he/she is individually obligating him/herself to pay the account of the Outpatient Clinic in accordance with its current rates and terms. I authorize Brattleboro Retreat to obtain my credit information for the sole purpose of collecting any unpaid self-pay balance.

I hereby authorize the Brattleboro Retreat to release information requested by the Insurance Company and/or its representative. The undersigned certifies that he/she has read the information attached, has received a copy and is the party responsible, or is duly authorized by the patient as his/her patient's general agent to execute the above and accept all terms listed therein.

Please list your current care providers:

Please choose 1 service. If you are seeking more than 1, please contact our staff to discuss options.

If someone else is submitting this referral, please provide the following:

TO THE CLIENT: You have the right, as a client, to be informed about your condition and the recommended medical or diagnostic treatment to be used so that you may make the decision whether or not to undergo any suggested treatment plan after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment plan for any identified condition(s).

This consent provides us with your permission to perform reasonable and necessary medical testing and treatment. By signing below, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; (2) you consent to treatment at this office. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue treatment and services.

You have the right to discuss the treatment plan with your provider about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommended by your health care provider, we encourage you to ask questions.

I voluntarily request a provider to perform reasonable and necessary testing and treatment for the condition which has brought me to seek care at this facility.

I understand that if additional testing and/or procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s).

I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.

*Unless otherwise indicated this consent is valid until revoked by the patient/guardian, or the patient is discharged.

I have the right to withhold or withdraw consent to telemedicine treatment at any time.

The laws that protect the confidentiality of my medical/healthcare information also apply to telemedicine. As such, I understand that the information disclosed by me during my therapy is generally confidential. However, there are mandatory exceptions to confidentiality, including reporting child, elder and dependent adult abuse, and the imminent risk of harm to myself or others. If I put my mental state at issue in certain legal proceedings, the psychotherapist may be compelled to release otherwise confidential information about my evaluation and treatment.

I understand that the dissemination of any personally identifiable images or information from telemedicine interactions shall not occur without my written consent. I also understand that sessions are not recorded, or videotaped, and separate written approval and consent is needed to record or videotape a session.

I understand that there are risks and consequences from telemedicine, including, but not limited to, the possibility, despite reasonable efforts on the part of my psychotherapist, that the transmission of my medical information could be interrupted or distorted by technical failures or unauthorized persons, and that the electronic communication of my medical information could be accessed by unauthorized persons.

I understand that telemedicine-based services and care may not be as complete or effective as face-to-face services. I understand that there are potential risks and benefits associated with any form of psychotherapy, and that despite my efforts and the efforts of my psychotherapist, my condition may not improve, and in some cases may get worse. I understand that I may benefit from telemedicine, but those results cannot be guaranteed or assured.

As with all medical records, I understand that I have a right to access my medical information and copies of medical records of telemedicine treatment in accordance with Vermont state laws.

I have read and understand the information provided above. My signature on the acknowledgement form indicates my informed and willful consent to treatment.

I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.

*Unless otherwise indicated this consent is valid until revoked by the patient/guardian, or the patient is discharged.

This orientation packet is meant to help answer some of your questions about treatment, attendance, participation, group norms, and our overall philosophy of treatment.

Our treatment philosophy at the Brattleboro Retreat is patient-centered and evidence-based. Our treatment varies depending on the program in which you are participating. Each program will provide you with more specific information related to that program alone. In this letter, our goal is to provide you with information that applies to all programs.

We provide an atmosphere of respect, empathy, and hope for people whose lives have been adversely affected by addiction and mental illness. At the Brattleboro Retreat we offer you support to learn and practice the skills that will lead to a healthier life.

Our staff members respect client independence always and expect each client to take responsibility for his or her own recovery.

Many Brattleboro Retreat services are covered by insurance including Medicaid. If you do not have insurance and you are a Vermont resident, you may be able to utilize state funds to pay for your treatment.

You may have a co-pay or co-insurance. This information will be discussed with you openly. Elsewhere in your intake paperwork is information related to our co-pay policy. It is your responsibility to make sure that we have your current insurance information as well as your current contact information (address, phone, etc.). We have staff who are willing and able to help you work out a payment plan if needed. If you have concerns about billing or insurance for particular programs, please reach out to Patient Financial Services at 1-888-738-7328.

If you or a family member has any concerns or complaints regarding the treatment that you have received at the Brattleboro Retreat please first discuss those concerns with your provider If you are not satisfied with your provider's resolution of your complaint, you may direct your concerns to the director of your program.

Concerns and complaints will then be discussed with the staff member(s) involved and a plan of action will be determined in each individual situation. If this process is insufficient, you may contact the Brattleboro Retreat Patient Advocate at 258-6118. In addition, at any time you may contact Disability Rights Vermont (DRVT), a non-profit legal advocacy agency for the rights of people with psychiatric disabilities, at 1-800-834-7890.

The background, qualifications, and areas of expertise of all our clinicians are available to you on the Brattleboro Retreat website, and upon request from any therapist or central registration staff.

The practice of all clinicians at the Brattleboro Retreat is governed by the rules of the disciplines in which practitioners are licensed. Professionals with certain licenses (LCMHC, LICSW, Psychologists, LMFT, LADC) as well as those on the roster of non-licensed and non- certified psychotherapists are also governed by the Rules of the Board of Allied Mental Health Practitioners. It is unprofessional conduct to violate those rules. The Vermont Secretary of State Office of Professional Regulation oversees professional conduct and maintains a procedure for consumers to make inquiries or register a complaint if problems cannot be resolved directly between the consumer and the clinician/clinic. To make a complaint, inquiry, or to obtain a copy of the rules, you can contact the Board online at https://www.sec.state.vt.us/professional-regulation.aspx or by calling (802) 828-2367.

The State has defined unprofessional conduct to include the following:

From 3 V.S.A. § 129a, applicable to licensed dinical mental health counselors, licensed marriage and family therapists, non-licensed and non-certified psychotherapists, licensed social workers, licensed psychologists, and licensed alcohol and drug abuse counselors:

(1) Fraudulent or deceptive procurement or use of a license.

(2) Advertising that is intended or has a tendency to deceive.

(3) Failing to comply with provisions of federal or state statutes or rules governing the practice of the profession.

(4) Failing to comply with an order of the board or violating any term or condition of a license restricted by the board.

(5) Practicing the profession when medically or psychologically unfit to do so.

(6) Delegating professional responsibilities to a person whom the licensed professional knows, or has reason to know, is not qualified by training,
experience, education, or licensing credentials to perform them, or knowingly providing professional supervision or serving as a preceptor to a person
who has not been licensed or registered as required by the laws of that person's profession.

(7) Willfully making or filing false reports or records in the practice of the profession, willfully impeding, or obstructing the proper making or filing of
reports or records, or willfully failing to file the proper reports or records.

(8) Failing to make available promptly to a person using professional health care services, that person's representative, or succeeding health care
professionals or institutions, upon written request and direction of the person using professional health care services, copies of that person's records
in the possession or under the control of the licensed practitioner, or failing to notify patients or clients how to obtain their records when a practice
closes.

(9) Failing to retain client records for a period of seven years unless laws specific to the profession allow for a shorter retention period. When other laws
or agency rules require retention for a longer period of time, the longer retention period shall apply.

(10) Conviction of a crime related to the practice of the profession or conviction of a felony, whether or not related to the practice of the profession.

(11) Failing to report to the office a conviction of any felony or misdemeanor offense in a Vermont District Court, a Vermont Superior Court, a federal court,
or a court outside Vermont within 30 days.

(12) Exercising undue influence on or taking improper advantage of a person using professional services or promoting the sale of services or goods in a
manner that exploits a person for the financial gain of the practitioner or a third party.

(13) Performing treatments or providing services that the licensee is not qualified to perform or that are beyond the scope of the licensee's education,
training, capabilities, experience, or scope of practice.

(14) Failing to report to the office within 30 days a change of name, email, or mailing address.

(15) Failing to exercise independent professional judgment in the performance of licensed activities when that judgment is necessary to avoid action
repugnant to the obligations of the profession.

(16)(A) Impeding an investigation under this chapter or unreasonably failing to reply, cooperate, or produce lawfully requested records in relation to such
investigation.

(B) The patient privilege set forth in 12 V.S.A. § 1612 shall not bar the licensee's obligations under this subsection (a) and a confidentiality agreement
entered into in concluding a settlement of a civil claim shall not exempt the licensee from fulfilling his or her obligations under this subdivision (16).

(17) Advertising, promoting, or recommending a therapy or treatment in a manner tending to deceive the public or to suggest a degree of reliability or
efficacy unsupported by competent evidence and professional judgment.

(18) Promotion by a treatment provider of the sale of drugs, devices, appliances, or goods provided for a patient or client in such a manner as to exploit
the patient or client for the financial gain of the treatment provider, or selling, prescribing, giving away, or administering drugs for other than legal
and legitimate therapeutic purposes.

(19) Willful misrepresentation in treatments or therapies.

(20) Offering, undertaking, or agreeing to cure or treat a disease or disorder by a secret method, procedure, treatment, or medicine.

(21) Permitting one's name or license to be used by a person, group, or corporation when not actually in charge of or responsible for the professional
services provided.

(22) Prescribing, selling, administering, distributing, ordering, or dispensing any druglegally classified as a controlled substance for the licensee's own use
or to an immediate family member as defined by rule.

(23) For any professional with prescribing authority, signing a blank or undated prescription form, or negligently failing to secure electronic means of
prescribing.

(24) For any mental health care provider, use of conversion therapy as defined in 18 V.S.A. § 8351 on a client younger than 18 years of age.

(25) (a) For providers of clinical care to patients, failing to have in place a plan for responsible disposition of patient health records in the event the
licensee should become incapacitated or unexpectedly discontinue practice.

(b) Failure to practice competently by reason of any cause on a single occasion or on multiple occasions may constitute unprofessional conduct, whether
actual injury to a client, patient, or customer has occurred. Failure to practice competently includes:

(1) performance of unsafe or unacceptable patient or client care; or

(2) failure to conform to the essential standards of acceptable and prevailing practice.

From: 26 V.S.A. § 3271, applicable to licensed clinical mental health counselors, licensed marriage and family therapists, and non-licensed and
non-certified psychotherapists:

(1) using dishonest or misleading advertising:

(2) misusing a title in professional activity;

(3) conduct that evidences unfitness to practice clinical mental health counseling

(4) engaging in any sexual conduct with a client, or with the immediate family member of a client, with whom the licensee has had a professional
relationship within the previous five years;

(5) harassing, intimidating, or abusing a client;

(6) entering into an additional relationship with a client, supervisee, research participant, or student that might impair the licensed clinical mental health
counselor's objectivity or otherwise interfere with the clinical mental health counselor's professional obligations;

(7) independently practicing outside or beyond a clinical mental health counselor's area of training, experience, or competence without appropriate
supervision; or

(8) using conversion therapy as defined in 18 V.S.A. § 8351 on a client younger than 18 years of age.

From 26 V.S.A. § 3210, applicable to licensed social workers:

(1) failing to use a correct title in professional activity;

(2) conduct which evidences unfitness to practice licensed master's or licensed independent clinical social work;

(3) engaging in any sexual conduct with a client, or with the immediate family member of a client, with whom the licensee has had a professional
relationship within the previous two years;

(4) harassing, intimidating, or abusing a client or patient;

(5) practicing outside or beyond a licensee's education, training, experience, or competence;

(6) having a conflict of interest that interferes with the exercise of the licensee's professional responsibilities, discretion and impartial judgment;

(7) failing to inform a client when a real or potential conflict of interest arises and failing to take reasonable steps to resolve the issue in a manner that
makes the client's interest primary and protects the client's interest to the greatest extent possible;

(8) taking unfair advantage of any professional relationship or exploiting others to further the licensee's personal, religious, political, or business interests;

(9) engaging in dual or multiple relationships with a client or former client in which there is a risk of exploitation or potential harm to the client;

(10) failing to take steps to protect a client and to set clear, appropriate, and culturally sensitive boundaries, in instances where dual or multiple
relationships are unavoidable;

(11) failing to clarify with all parties which individuals will be considered clients and the nature of the licensee's professional obligations to the various
individuals who are receiving services, when a licensee provides services to two or more people who have a spousal, familial, or other relationship
with each other;

(12) failing to clarify the licensee's role with the parties involved and to take appropriate action to minimize any conflicts of interest, when the clinical
social worker anticipates a conflict of interest among the individuals receiving services or anticipates having to perform in conflicting roles such as
testifying in a child custody dispute or divorce proceedings involving clients; or

(13) using conversion therapy as defined in 18 V.S.A § 8351 on a client younger than 18 years of age.

From: 26 VSA § 3016, applicable to licensed psychologists:
(1) Failing to make available, upon written request of a person using psychological services to succeeding health care professionals or institutions, copies
of that person's records in the possession or under the control of the licensee.
(2) Failing to use a complete title in professional activity.
(3) Conduct that evidences moral unfitness to practice psychology.
(4) Engaging in any sexual conduct with a client, or with the immediate family member of a client, with whom the licensee has had a professional
relationship within the previous two years.
(5) Harassing, intimidating, or abusing a client or patient.
(6) Entering into an additional relationship with a client, supervisee, research participant, or student that might impair the psychologist's objectivity or
otherwise interfere with the psychologist's professional obligations.
(7) Practicing outside or beyond a psychologist's area of training or competence without appropriate supervision.
(8) In the course of practice, failure to use and exercise that degree of care, skill, and proficiency that is commonly exercised by the ordinary skillful, careful,
and prudent psychologist engaged in similar practice under the same or similar conditions, whether or not actual injury to a client or patient has occurred.
(9) Conduct that violates the "Ethical Principles of Psychologists and Code of Conduct" of the American Psychological Association, effective December 1,
1992, or its successor principles and code.
(10) Conduct that violates the "ASPPB Code of Conduct-1990" of the Association of State and Provincial Psychology Boards, or its successor code.
(11) Use of conversion therapy as defined in 18 V.S.A. § 8351 on a client younger than 18 years of age.
From 26 VSA § 3239, applicable to alcohol and drug abuse counselors:
(1) violation of any provision of this chapter or rule adopted under this chapter;
(2) failing to use a complete title in professional activity;
(3) conduct that evidences moral unfitness to practice alcohol and drug abuse counseling
(4) negligent, incompetent, or wrongful conduct in the practice of alcohol and drug abuse counseling; or
(5) harassing, intimidating, or abusing a client.
In addition, if you have concerns about your physician, you can call the Vermont Board of Medical Practice at (802) 657-4220, and if you have concerns
about the facility, you can call the Centers for Medicare & Medicaid Services at (802) 828-2903.
Further information or clarification regarding what constitutes unprofessional conduct and how to make an inquiry or register a complaint is available
through your clinician or Brattleboro Retreat Administrative Staff and also posted in Brattleboro Retreat waiting areas.

My signature acknowledges that I have been given a listing of actions that constitute unprofessional conduct according to
Vermont statutes, and the method for making a consumer inquiry or filing a complaint with the Office of Professional
Regulation. I acknowledge that information about the credentials of the staff in the program are available in public areas in
which treatment is provided, on the Retreat's website, or by request from administrative or clinical staff at any time.

This notice describes how medical 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 Michael Methe, the Brattleboro Retreat's Privacy Officer (scroll to bottom of page).

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 health 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 by 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.

Your PHI may be used and disclosed by your treatment provider, our office staff, and others outside of our office who are 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 the treatment provider.

Following are examples of the types of uses and disclosures of your protected health care information that the Treatment Provider 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.

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 a third party that has already obtained your permission to have access to your protected health information. 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 Treatment Providers who may be treating you when we have the necessary permission from you to disclose your protected health information. For example, your protected health information may be provided to a Treatment Provider to whom you have been referred to ensure that the Treatment Provider has the necessary information to diagnose or treat you.

In addition, we may disclose your protected health information from time-to-time to another Treatment Provider or health care provider (e.g., a specialist or laboratory) who, at the request of your Treatment Provider, becomes involved in your care by providing assistance with your health care diagnosis or treatment to your Treatment Provider.

Your protected health information will be used, as needed, to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as:

• Making a determination of eligibility or coverage for insurance benefits
• Reviewing services provided to you for medical necessity
• 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).

We may use or disclose, as-needed, your protected health information in order to support the business activities of your treatment provider'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.

For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your Treatment Provider. We may also call you by name in the waiting room when your Treatment Provider is ready to see you. We may contact you by telephone to remind you of your appointments.

We will share your protected health information with third party "business associates" that perform various activities (e.g., billing, and transcription services) for the practice. Whenever an arrangement between our office and a business associate

involves the use or 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 your 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.

We may use certain information (name, address, telephone number, dates of service, age, program name and guarantor) to contact you in the future to raise money for Brattleboro Retreat. The money raised will be used to expand and improve the services and programs we provide the community.

If you do not wish to be contacted for fund-raising efforts, please notify the Office of Development at Brattleboro Retreat, Anna Marsh Lane, P. O. Box 803, Brattleboro, VT 05302 in writing or email unsubscribe@brattlebororetreat.org

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, at any time, in writing, except to the extent that your Treatment Provider has taken an action in reliance on the use or disclosure indicated in the authorization.

We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or 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 Treatment Provider may, using professional judgement, determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your health care will be disclosed.

Others Involved in Your Healthcare: With your written authorization, 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 based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is 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 health care.

Emergencies: We may use or disclose your protected health information in an emergency treatment situation. If this happens, your Treatment Provider shall try to obtain your consent as soon as reasonably practicable after the delivery of treatment. If your Treatment Provider or another Treatment Provider in the facility is required by law to treat you and the Treatment Provider has attempted to obtain your consent but is unable to obtain your consent, he or she may still use or disclose your protected health information to treat you.

Communication Barriers: We may use and disclose your protected health information if your Treatment Provider or another Treatment Provider in the facility attempts to obtain consent from you but is unable to do so due to substantial communication barriers and the treatment provider determines, using professional judgement, that you intend to consent to use or disclosure under the circumstances.

Required By Law: We may use or disclose your protected health information to the extent that the use or 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, as required by law, of any such uses 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. The disclosure will be made for the purpose of controlling disease, injury or disability. We may also disclose your protected health information, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority.

Communicable Diseases: 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 spreading 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 or Neglect: We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect 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.

Food and Drug Administration: We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.

Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), 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 otherwise 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 the practice, and (6) medical emergency (not on the Practice's 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 purposes.

Research: We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information, or with your written approval.

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.

Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities including for the provision of protective services to the President or others legally authorized.

Workers' Compensation: we may disclose your protected health information as authorized to comply with workers' compensation laws and other similar legally established programs.

Inmates: We may use or disclose your protected health information if you are an inmate of a correctional facility and your Treatment Provider created or received your protected health information in the course of providing care to you.

Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et. seq.

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 that is contained in a designated record set for as long as we maintain the protected health information. A "designated record set" contains medical and billing records and any other records that your Treatment Provider uses for making decisions about you.

Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is 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 healthcare 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 Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.

Your Treatment Provider is not required to agree to a restriction that you may request. If your Treatment Provider believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. If your Treatment Provider 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 Treatment Provider. You may request a restriction by filling out the appropriate form available in the Admissions department.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled 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 Treatment Provider amend your protected health information. This means you may request an amendment of protected health information about you in a designated record set for as 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. Please contact our Privacy Officer with questions you may have 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 healthcare operations as described in this Notice of Privacy Practices and all disclosures made pursuant to a signed authorization. It excludes disclosures we may have made to you, for a facility directory, to family members or friends involved in your care, or for notification purposes. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003. You may request a shorter time frame. 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.

You may complain to us or to the Secretary of Health and Human Services if you believe we have violated your privacy rights. 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.

Contact information for Privacy Officer: Michael Methe, Brattleboro Retreat, 1 Anna Marsh Lane P.O. Box 803 Brattleboro, VT 05302 Phone # 802-258-4333

I have received the Notice of Privacy Practices at the Brattleboro Retreat informing me of how my personal health information will be used.

My understanding of this Notice will help me to ensure the accuracy of my health information, better understand who, what, when, where and why others may access my health information.

I understand the contents of the Notice of Privacy Practices at the Brattleboro Retreat.