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TRIAPATH — NOTICE OF PRIVACY PRACTICES

Notice of Privacy Practices of Tria Health LLC d/b/a TriaPath

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.

This notice also explains your rights, our legal duties, how to file a complaint, and the extra protection that federal law (42 CFR Part 2) gives to substance use disorder treatment records from our SAIOP program. You can ask for a paper or electronic copy at any time. You can also ask to talk about it with our Privacy Officer.

Effective date: October 14, 2026.

Who follows this notice

Tria Health LLC d/b/a TriaPath (“TriaPath”) and all of our staff, students and volunteers, at all of our locations and when we provide services by telehealth. TriaPath runs outpatient therapy and a substance use disorder treatment program (SAIOP) that is covered by 42 CFR Part 2.

Your rights

When it comes to your health information, you have the right to:

• Get a copy of your record. Ask to see or get a paper or electronic copy of your health record. We will usually respond within 30 days. If we ever charge a fee, it will be a reasonable, cost-based fee, and we will tell you first.
• Ask us to correct your record. If you think information is wrong or missing, ask us in writing to correct it. We may say no, but we will tell you why in writing within 60 days.
• Ask for private ways to contact you. Ask us to contact you a certain way, for example only on your cell phone, or at a different address. We will say yes to all reasonable requests.
• Ask us to limit what we use or share. You can ask us not to use or share certain information for treatment, payment or our operations. We do not have to agree if it would affect your care. If you pay for a service in full out of pocket, you can ask us not to share it with your health plan. We will say yes unless a law requires us to share it.
• Get a list of those we shared your information with (an “accounting of disclosures”). Ask for a list of the times we shared your information in the 6 years before you ask, who we shared it with, and why. It will not include sharing for treatment, payment and operations, and some other sharing, such as sharing you asked us to make. One list a year is free. If you ask for another within 12 months, we may charge a reasonable, cost-based fee.
• Get a copy of this notice, on paper or electronically, at any time, even if you agreed to get it electronically.
• Choose someone to act for you. If you have a legal guardian, or gave someone medical power of attorney, that person can use your rights and make choices about your health information. We will check that the person has this authority before we act.
• Talk with us about this notice. Contact our Privacy Officer (details at the end).
• File a complaint if you feel your rights were violated (see “Complaints” below).

How we use and share your information

We usually use or share your health information in these ways:

• To treat you. We use your information, and share it with professionals who are treating you. Example: your counselor and the Clinical Director talk about your treatment plan.
• To run our organization. We use your information to run our practice, improve your care, train staff, and meet licensing and accreditation standards. Example: we review charts to check the quality of our services.
• To bill for your services. We use and share your information to bill and get paid by NC Medicaid and your Medicaid health plan. Example: we give your health plan information about your visit so it can pay us.

North Carolina law (N.C. Gen. Stat. Chapter 122C) gives mental health and substance use records extra protection. Records from our SAIOP program have even stronger protection under 42 CFR Part 2 (see below). When another law is stricter than HIPAA, we follow the stricter law.

Other ways we may share without your written permission

We may share your information in the ways below only when the law allows or requires it, and only the minimum needed. For SAIOP records, most of these need your written consent or a special court order. See the 42 CFR Part 2 section below.

• When a law requires it, including when the U.S. Department of Health and Human Services checks that we follow privacy law.
• To report suspected abuse, neglect or exploitation of a child, or of an older adult or an adult with a disability, as North Carolina law requires.
• To prevent a serious threat to anyone’s health or safety. We share only with someone who can help prevent the threat.
• For public health activities, such as reporting certain diseases or problems with medicines.
• For health oversight, such as audits, investigations and licensing reviews by NC Medicaid, NC DHHS and accrediting bodies.
• For a lawsuit or legal action: in response to a court order, or in some cases a subpoena, after efforts to tell you or to protect your information.
• For law enforcement, only in the limited cases the law allows, such as a crime on our premises.
• To coroners, medical examiners and funeral directors when someone dies.
• For organ and tissue donation requests.
• For research, only under strict rules that protect your privacy, such as approval by a review board.
• For special government needs, such as the military, national security, or protecting the President. Also if you are held in a jail or prison, or by law enforcement.
• For workers’ compensation claims.
• To business associates: companies that do work for us, such as our secure cloud and computer services. They must sign a contract to protect your information.

Family, friends and others involved in your care

Because North Carolina law gives mental health and substance use records extra protection, we share information with your family, friends or others involved in your care only with your written permission. In an emergency when you cannot give permission, we may share what is needed to help you, as the law allows. For SAIOP records, we may share only with medical staff treating you.

Your Emergency Contact form tells us whom we may call in an emergency and what we may say.

Uses that always need your written permission

• Marketing: we will never use your information for marketing without your written permission.
• Sale of information: we will never sell your information.
• Psychotherapy notes: most sharing of a therapist's separate psychotherapy notes, if any are kept, needs your written permission.
• Substance use disorder counseling notes: notes a SAIOP counselor keeps apart from your record can be shared only with your separate written consent.
• Fundraising: we do not use your information for fundraising. If that ever changes, we will first give you a clear chance to say no to fundraising messages.

We will not use or share your information in any other way that is not described in this notice unless you give us written permission. You can take back (revoke) your permission at any time, in writing, except for anything we already did based on it.

Information we share as this notice allows may be shared again by the person who receives it, and may then no longer be protected by federal privacy law. SAIOP records keep the extra protection described below.

Substance use disorder records from our SAIOP program (42 CFR Part 2)

Federal law (42 CFR Part 2) protects the confidentiality of substance use disorder treatment records. Records from our SAIOP program are covered. In general, we may not tell anyone outside TriaPath that you are in our program, or share any information that identifies you as having a substance use disorder, unless:

• you agree in writing, on a consent form that meets 42 CFR Part 2;
• a court order allows it, under the special 42 CFR Part 2 rules;
• it is shared with medical staff in a medical emergency;
• it is shared for research, audits or program evaluations under strict federal rules;
• it is shared with an organization that provides services to us under a written agreement that protects your information;
• it is needed to report a crime on our premises or against our staff, or a threat to commit one; or
• it is a first report of suspected child abuse or neglect that North Carolina law requires.

Federal law does not protect information about a crime committed by a patient at the program or against program staff, or about a threat to commit such a crime. Federal law does not protect information about suspected child abuse or neglect from being reported to state or local authorities under state law.

Examples of sharing that needs your written consent: sharing with your family, an employer, a school, a court, a probation or parole officer, or a health care provider outside TriaPath.

One consent for treatment, payment and health care operations. You may sign one consent that lets us use and share your SAIOP records for all future treatment, payment and health care operations. Health care providers and health plans that receive your records under that consent may share them again as HIPAA allows, but never for legal proceedings against you.

Legal proceedings. Your SAIOP records cannot be used or shared against you in an investigation or a case. This covers civil, criminal, administrative and legislative proceedings, and testimony about what is in your records. The only exceptions are your specific written consent, or a court order. A court may order it only after you and TriaPath are given notice and a chance to be heard, as the rules require. The court order must come with a subpoena or other legal requirement that forces the disclosure.

Taking back a consent. You can revoke a 42 CFR Part 2 consent at any time, in writing, except for anything already done based on it. Tell any staff member or our Privacy Officer, and we will help you put it in writing.

Your extra rights for SAIOP records

• Ask us to limit what we share under your consent for treatment, payment and operations. We do not have to agree, except that if you paid for a service in full out of pocket, you can ask us not to share it with your health plan, and we will agree unless a law requires it.
• Get a list (accounting) of disclosures of your electronic records for the past 3 years, and a list of other disclosures we made with your consent.
• If your records were shared through an intermediary, such as a health information exchange, get a list of who received them through it in the past 3 years.
• Choose not to get fundraising messages. (TriaPath does not fundraise.)
• Get a paper or electronic copy of this notice, and talk with our Privacy Officer about it.
• Complain to us and to the U.S. Department of Health and Human Services if you believe your rights were violated (see “Complaints”). We will never ask you to give up this right in order to get treatment.

Our responsibilities

• The law requires us to keep your health information private and secure. It also requires us to give you this notice of our legal duties and privacy practices.
• If a breach happens that may have put your information at risk, we will tell you promptly.
• We must follow the duties and privacy practices in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can, in writing.

Changes to this notice

We can change this notice, and the changes will apply to all information we have about you. The new notice will be available when you ask, in our office, and on our website (triapath.com). We will offer you the new notice at your next visit.

Complaints

If you feel we have violated your privacy rights, you can complain to us. Contact Tanya Palacios, Privacy Officer, Tria Health LLC d/b/a TriaPath, 4408 Piedmont Trace Dr, Greensboro, NC 27409. Phone (757) 630-2309. Email info@triapath.com. You can complain by phone, email, letter or in person. We will help you put it in writing.

You can also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights: write to 200 Independence Avenue S.W., Washington, D.C. 20201, call 1-877-696-6775, or visit www.hhs.gov/ocr/privacy/hipaa/complaints/. This includes complaints about 42 CFR Part 2.

We will not retaliate against you for filing a complaint.

Questions about this notice

Tanya Palacios, Privacy Officer · Tria Health LLC d/b/a TriaPath · 4408 Piedmont Trace Dr, Greensboro, NC 27409 · (757) 630-2309 · info@triapath.com.

Effective date of this notice: October 14, 2026.

Acknowledgment of receipt

By signing below, you confirm that you received (or were offered) a copy of TriaPath's Notice of Privacy Practices. Signing does not mean you agree with it, and it does not change your rights. If you choose not to sign, we will write down that you were given the notice and why you did not sign.

By signing below, I confirm that:

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TRIAPATH — CONSENT FOR SERVICES

This form is called a Consent for Services. It explains how treatment works at Tria Health LLC d/b/a TriaPath (“TriaPath”), what you can expect from us, and what we ask of you. Please read it before you start services. If anything is unclear, ask us. We are glad to explain.

In this form, “we” and “us” mean TriaPath and its staff. “You” means the person getting services. If you are under 18, it also means your parent or guardian.

Who we are

TriaPath is a behavioral health provider in North Carolina. Our office is at 4408 Piedmont Trace Dr, Greensboro, NC 27409. Phone: (757) 630-2309. Email: info@triapath.com. Website: triapath.com. We offer two programs:

• SAIOP (Substance Abuse Intensive Outpatient Program): group and individual treatment for substance use, at least 3 hours a day, 3 days a week.
• Outpatient therapy: individual counseling for mental health and substance use concerns.

How treatment works

Treatment works best when you and your counselor work as a team toward goals you choose. Research shows that people who take part in each step, and who have a good working relationship with their counselor, usually do better. These are the steps:

• Intake. We go over this form and our policies, check your Medicaid coverage, and ask who to call in an emergency.
• Assessment. Your counselor asks about your health, substance use, mental health, family and daily life. This helps us recommend the right care. We also use short questionnaires at the start, during and at the end of treatment to see how you are doing.
• Treatment plan. Together, you write down your goals, the services you will get, how often, and the steps you will take. We review and update the plan with you over time.
• Sessions. You take part in sessions at our office or by telehealth (secure video or phone).
• Discharge. When you reach your goals, or decide to stop, we review your progress together. We plan the support you need to stay well and explain how to come back if you need us.

Your choice and our team

Treatment is voluntary. You can stop at any time. We ask that you tell us first, so we can help you plan your next steps.

Some of our counselors have an associate or provisional license. They work under the supervision of a fully licensed clinician. If your counselor is supervised, they will tell you and give you the name of their supervisor (it is also written below). Supervisors may read your record and talk about your care to make sure you get good care.

Clinical care at TriaPath is overseen by Katherine Davis, Clinical Director.

Benefits and risks

Treatment can help you feel better, cut down or stop using alcohol or drugs, handle stress, improve your relationships and reach your goals. We cannot promise results.

Treatment can also be hard at times. You may talk about painful memories or feel strong emotions for a while. Changes you make may affect people close to you. If treatment feels too hard, tell your counselor. Together you can change the pace or the plan.

Telehealth

Some sessions may happen by secure video or by phone. This is called telehealth. Every client also signs our Telehealth Agreement. It explains the risks and benefits, how to keep your session private, and our plan for emergencies. You can always ask to be seen in person instead.

Your privacy

What you tell us is private. We protect it under federal privacy law (HIPAA) and North Carolina law. SAIOP records also have extra protection under a federal law for substance use treatment records (42 CFR Part 2). Our Notice of Privacy Practices explains your privacy rights in full.

When the law allows or requires us to share information without your permission, we share only the minimum needed.

When we may share without your permission — For Outpatient Therapy (OPT) clients

There are a few times when the law allows or requires us to share information without your written permission:

• With staff at TriaPath and other health care providers who are treating you, to coordinate your care.
• With emergency medical staff, if you need emergency care.
• With NC Medicaid and your Medicaid health plan, so we get paid and to meet their review rules.
• If we believe a child, an older adult or an adult with a disability is being abused, neglected or exploited. North Carolina law requires us to report it.
• If we believe there is an imminent danger to you or to someone else, for example a specific, believable threat to hurt someone. North Carolina law allows us to warn the person at risk and to contact law enforcement.
• If you are at immediate risk of seriously hurting yourself. We may contact crisis services or law enforcement. Before we do, we will try to work with you on other ways to keep you safe.
• If a court orders it, or another law requires it, such as an audit by a government agency.
• If you tell us that another health professional acted improperly, we may have to report it to their licensing board. We will talk with you first and share only what is needed.

Extra protection for SAIOP records (42 CFR Part 2) — For SAIOP (substance use program) clients

Because you are in SAIOP, your substance use treatment records have extra protection under federal law (42 CFR Part 2). In most cases, we cannot tell anyone outside TriaPath that you are in treatment with us, or share any information about you, unless you give written consent. Staff inside our program may share information when they need it to treat you. The exceptions are:

• A medical emergency: we may share with medical staff who are treating you.
• Suspected child abuse or neglect: we must make the first report that North Carolina law requires.
• A crime at TriaPath or against our staff, or a threat to commit one: we may report it to law enforcement.
• Audits, program reviews and research: only under strict federal rules that protect your identity.
• Companies that provide services to us, such as our secure computer systems: only under written agreements that require them to protect your information.
• A special court order that follows 42 CFR Part 2. A subpoena alone is not enough.

For SAIOP (substance use program) clients:

If we believe someone is in danger, we may warn them or call for help without saying that you are in substance use treatment.

Your substance use treatment records, or testimony about what is in them, cannot be used against you in any criminal, civil, administrative or legislative proceeding. The only exceptions are if you give specific written consent, or if a court orders it after you are given notice and a chance to be heard.

You will be asked to sign a separate 42 CFR Part 2 consent, so we can share information for your treatment, to bill NC Medicaid, and to run our program. You choose anyone else we may share with by signing a Release of Information.

Your records

We must keep records of your treatment. Records keep your care safe and consistent. They also show that your services meet professional and NC Medicaid standards.

Your records are kept in TriaPath's own electronic health record (EHR). It runs on Google Cloud under a HIPAA Business Associate Agreement, a contract that requires Google to protect your information. The system keeps a log of every log-in and every action, so we can see who looked at or changed a record, and when. Only staff who are part of your care can open your chart.

You have the right to see your records and get a copy. Our Notice of Privacy Practices explains how. We keep records for as long as state and federal rules require, then destroy them securely.

How we contact each other

You choose how we may contact you between sessions. Your choices are written below. You can change them at any time.

• Phone calls are the best way to reach us. If you call after hours, leave a message and we will call you back on the next business day.
• Text messages and regular email are not fully secure. Other people could see them, for example if they use your phone. If you agree, we may use them for appointment reminders and scheduling only. Please do not text or email us about a crisis or private details.
• Our messages will not say what kind of services you get.
• Social media: to protect your privacy, staff will not accept friend or follow requests from clients, and will not reply to comments, mentions or direct messages. We do not ask for online reviews and we do not reply to them, so we never confirm that you are a client. If you post a review, think about how much you share.

Paying for services: NC Medicaid

TriaPath serves people with NC Medicaid: NC Medicaid Direct, Standard Plans and Tailored Plans. We do not accept private (commercial) insurance. NC Medicaid pays us directly. You will also sign a separate Consent to Bill NC Medicaid.

• You will never be charged for services that NC Medicaid covers.
• You will never be charged for a missed appointment or a late cancellation.
• We do not keep a credit card on file, and we do not send bills to collections.
• We check your Medicaid eligibility every month.
• Please tell us right away if your Medicaid changes: a new health plan, a new Medicaid ID, a move, or if your coverage ends. If your coverage ends, we will talk with you about your options before your next session.
• If you also have other health insurance, such as Medicare or a plan through a job, please tell us. Medicaid rules require it.

Ending services

You may end services at any time. We may also recommend ending or changing your services if you have reached your goals, if you need a different level of care, if you stop coming and we cannot reach you, or if there is a safety problem we cannot manage here. Whenever we can, we will talk with you first and give you referrals to other services.

Concerns and complaints

If you are unhappy with your care, please tell us. You can talk with your counselor or with Katherine Davis, Clinical Director. For privacy concerns, contact Tanya Palacios, Privacy Officer. Call (757) 630-2309 or email info@triapath.com. You will not lose services or be treated differently for making a complaint. You may also contact:

• Your Medicaid health plan's Member Services. Every plan has a grievance process. The phone number is on your Medicaid card.
• NC Medicaid Ombudsman (free help with Medicaid problems): 1-877-201-3750.
• NC Division of Health Service Regulation, Complaint Intake Unit: 1-800-624-3004.
• The licensing board of the staff member involved, for example the NC Board of Licensed Clinical Mental Health Counselors (ncblcmhc.org) or the NC Addiction Specialist Professional Practice Board (ncasppb.org).
• For privacy complaints: U.S. Department of Health and Human Services, Office for Civil Rights, 200 Independence Avenue S.W., Washington, D.C. 20201 · 1-877-696-6775 · www.hhs.gov/ocr/privacy/hipaa/complaints/.

Reporting a 42 CFR Part 2 violation — For SAIOP (substance use program) clients

If you believe TriaPath, or anyone who received your SAIOP records, broke the 42 CFR Part 2 rules, you can complain to us and to the U.S. Department of Health and Human Services (Office for Civil Rights). You file it the same way as a HIPAA privacy complaint, using the contact details above. We will never retaliate against you. We will never ask you to give up your right to complain in order to get treatment.

In a crisis

TriaPath is not an emergency service. If you need help right away:

• In danger or a medical emergency: call 911 or go to the nearest emergency room.
• 988 Suicide & Crisis Lifeline: call or text 988, or chat at 988lifeline.org. It is free, private and open 24 hours a day. You can ask for a mobile crisis team to come to you.
• Guilford County Behavioral Health Center — walk-in crisis care, open 24 hours: 931 Third Street, Greensboro, NC 27405 · (336) 890-2700. If you live in another county, we will give you your local center.
• Your Medicaid health plan's behavioral health crisis line (24 hours a day). The number is on your Medicaid card.
• NC Peer Warmline — talk with someone who has been there (not for emergencies): 1-855-733-7762.
• TriaPath: (757) 630-2309 during office hours. After hours, leave a message. Our phone is not a crisis line.

Your consent

By signing, you confirm that you read this form (or it was read to you), that your questions were answered, and that you agree to receive services from TriaPath. You may withdraw this consent at any time by telling us in writing. Withdrawing does not undo anything already done.

By signing below, I confirm that:

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TRIAPATH — TELEHEALTH AGREEMENT

What telehealth is

Telehealth means getting services from TriaPath by secure video, or by phone when video is not possible, instead of meeting in our office. Every TriaPath client signs this agreement, even if you plan to come in person. That way you are ready if a session has to move online.

Telehealth sessions follow the same standards of care as sessions in our office. There is no charge to you for telehealth.

How it works

• We use a secure video service that is covered by a HIPAA Business Associate Agreement. We will send you a link and show you how to join.
• You need a phone, tablet or computer with a camera and microphone, and an internet connection. Phone-only (audio) sessions may be used when video does not work, if NC Medicaid rules allow it and it is right for you.
• At your first telehealth session we confirm who you are with two pieces of identification, for example your name and date of birth, or a photo ID shown on camera.
• At the start of every session we ask where you are, so we can send help if it is ever needed.
• Your counselor must be allowed to practice where you are. If you will be outside North Carolina, tell us before the session. We may need to reschedule.

Benefits

• You can join from any private place that is convenient for you.
• No travel time or transportation costs.
• You can keep your appointment during bad weather or a minor illness.

Risks

• Privacy: someone near you could overhear you or see your screen. A telehealth app may ask for your name, date of birth and contact details. We choose services that protect your information to HIPAA standards.
• Technology: the internet, video or sound can fail. If that happens, we follow the backup plan below.
• Crisis: it can be harder for us to help you right away in an emergency when we are not in the same room. That is why we make the emergency plan below.
• Telehealth is not right for everyone or for every situation. If we think care in our office is safer or better for you, we will tell you.

Keeping your session private

• Use a private space where others cannot hear you or see your screen. Headphones help.
• Do not join while you are driving.
• Use your own device and a secure network when you can. Avoid public Wi-Fi.
• In group sessions (SAIOP), make sure no one else is in the room or can hear. Never share other members' names, faces or stories.
• Do not record any session (video, audio or screenshots) unless everyone agrees in writing. TriaPath will not record sessions without your written permission.
• Our staff also join from private, secure spaces and use headsets.

If the connection drops

If the video stops, wait 2 minutes and try the link again. If that does not work, your counselor will call you at the backup phone number below. If we cannot reconnect, we will reschedule. You will not be charged.

Emergency plan

• At the start of each session, tell us the address or place where you are.
• If you are in danger during a session, your counselor may call 911 or local emergency services to your location. We may also call your emergency contact, as your Emergency Contact form allows.
• Telehealth is not for emergencies. If you need help now, do not wait for a session. Call or text 988, or call 911.

For SAIOP clients: in a medical emergency we may share needed information with medical staff, such as paramedics. We contact your emergency contact only as your signed Emergency Contact form allows (42 CFR Part 2).

Your choices

• You do not have to use telehealth. You can ask for services in person at any time.
• You can take back this agreement at any time by telling us. This does not affect your right to services.

By signing below, I confirm that:

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TRIAPATH — CONSENT TO BILL NC MEDICAID

What this consent is for

TriaPath is paid by NC Medicaid. This form lets us bill NC Medicaid and your Medicaid health plan for the services you get, and share the information they need to pay us.

What I agree to

• I allow Tria Health LLC d/b/a TriaPath (NPI 1366368813) to bill NC Medicaid for my services. This may be through NC Medicaid Direct or my Medicaid health plan, such as a Standard Plan or a Tailored Plan.
• I ask that payment go directly to TriaPath.
• I allow TriaPath to share the minimum information needed to get paid and to meet Medicaid rules. This includes my name, date of birth, Medicaid ID, address, diagnosis, and the dates and types of my services. When my plan asks for them to approve or review services, it also includes my assessment, treatment plan and session notes.
• I allow TriaPath to check my Medicaid eligibility each month.
• I understand that NC Medicaid, my health plan and other agencies that oversee Medicaid may review this information in audits.

What you will never be charged for

• You will not be charged for any service that NC Medicaid covers.
• You will not be charged for missed or late-cancelled appointments.
• We do not keep a credit card on file, and we do not send bills to collections.
• If a service is not covered, we will tell you before the service and help you find other options.

What we ask of you

• Show us your Medicaid card at intake and whenever it changes.
• Tell us right away if your health plan, Medicaid ID, address or eligibility changes, or if you get other health insurance, such as Medicare.
• Renew your Medicaid on time. We can tell you how to reach your county Department of Social Services.

SAIOP and 42 CFR Part 2 — For SAIOP (substance use program) clients

Billing for SAIOP shares substance use treatment information with NC Medicaid and your health plan. Federal law (42 CFR Part 2) requires your written consent for this. Your separate 42 CFR Part 2 consent for treatment, payment and health care operations covers it. This form does not replace that consent.

Changing your mind

You can take back (revoke) this consent at any time by telling us in writing. Revoking does not undo bills already sent for services you received before you revoked it. If you revoke it, we will not be able to bill Medicaid for future services, so we will talk with you about other options.

This consent stays in effect while you get services at TriaPath, unless you revoke it.

By signing below, I confirm that:

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