ATTENTION HOMES, INC.

NOTICE OF PRIVACY PRACTICES

Effective Date of Notice: April 14, 2003

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU FOR SERVICES DELIVERED AT ATTENTION HOMES MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Responsibility to Our Clients:

Attention Homes is obligated by law to give you notice of our privacy practices. This notice describes how we protect your health information and what right you have regarding it. We will abide by the terms of this notice. We will not use or disclose your health information without your authorization, except as described in this notice.

Attention Homes reserves the right to change this Notice and to make the revised or changed notice effective for health information it already has about you as well as any information received in the future. A copy of a current Notice will be posted at all times in the resident’s common areas. If you have questions about your privacy rights as described in this Notice and/or about our responsibilities as to your health information, please contact Attention Homes’ Privacy Officer at the following address and/or phone number:

Privacy Officer

Attention Homes, Inc.

P.O.Box 687

Cheyenne, WY 82003

(307) 778-7832

How We May Use and Disclose Health Information About You:

1. Treatment: Your health information will be used and disclosed in the course of providing, coordinating and/or managing your health care and related services provided at Attention Homes by members of the treatment team. This may include making disclosures of health information about you to your family members, your personal representative, or other persons identified by you who are involved in your health care. Examples of how we use or disclose information for treatment purposes are: Information obtained by a youth care counselor, house supervisor, therapist or other health care provider will be recorded in your medical record and used in determining the course of your treatment. This information will also be shared with DFS caseworkers, court officials such as Assistant District Attorneys, Guardian Ad Litums and Judges.

2. Payment: We will use your health information in order to bill and collect payment from the Wyoming Department of Family Services, the Wyoming State Department of Education, the Wyoming Department of Health, parents, funding agencies in other states, an insurance company or other third-party payers for services you receive at Attention Homes. For example, if you have been court ordered to Attention Homes, a copy of your clinical assessment and treatment plan will be provided to your DFS caseworker, Guardian Ad Litum and District Attorney’s office. If you are a private pay client, these treatment reports will be sent to your parents or legal guardians and an insurance company that is providing funding for your treatment.

3. Healthcare Operations: Health care operations mean those administrative and managerial functions that we have to do to run our agency, including continuous quality improvement activities. Our health care operations include, among other things, the following functions: quality assessment and improvement activities; reviewing the qualifications and performance of health care providers; accreditation; licensing; legal and auditing activities; business planning and development. For example, your health information could be used to assist in the evaluation of the quality of care that you were provided, or your information may be combined with health information of other clients to evaluate the need for new services or treatment.

4. Client Surveys: You may receive a survey after discharge from Attention Homes requesting your evaluation of the care and other services provided to you while a client at Attention Homes.

USES AND DISCLOSURES OF HEALTH INFORMATION FOR OTHER REASONS WITHOUT PERMISSION:

In some limited situations, the law allows or requires us to use or disclose your health information without your permission. Not all of these situations will apply to us; some may never come up at our agency at all. Such uses or disclosures are:

when a state or federal law mandates that certain health information be reported for a specific purpose;

for public health purposes, such as contagious disease reporting, investigation or surveillance in order to prevent or control disease, injury or disability;

to a social service or law enforcement agency authorized by law to receive reports of abuse, neglect or domestic violence;

uses and disclosures for health oversight activities such as audits by Medicaid, or for investigation of possible violations of health care laws;

disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies;

to law enforcement officials as required by law or in response to a valid court order, subpoena or warrant, or in response to an official request for the purpose of identifying or locating a missing person, suspect or fugitive;

disclosures of a “limited data set” for research, public health, or health care operations;

to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we also may release information in order for funeral directors to perform their jobs.

to organ procurement organizations or other entities engaged in procurement, banking or transplantation of organs/tissues for the purpose of transplant or donation;

to the Food and Drug Administration (FDA) relative to adverse events with respect to food, medications, products and product defects to facilitate product recalls, repairs or replacement, or for post marketing surveillance;

to avert a serious threat to health or safety to you, or that of the public or of another person able to help prevent the threat;

to authorized federal officials for conduct of intelligence or national security activities, including protective services to the President or other persons as authorized by law.

disclosures to “business associates” who perform health care operations for us and who commit to respect the privacy of your health information.

OTHER USES AND DISCLOSURES

We will not make any other uses or disclosures of your health information unless you sign a written “authorization form.” The content of an “authorization form” is determined by Federal law. Sometimes, we may initiate the authorization process if the use or disclosure is our idea. Sometimes, you or your legal guardian may initiate the process if it’s your idea for us to send your information to someone else. Typically, in this situation you will give us a properly completed authorization form, or you can use one of ours.

If we initiate the process and ask you to sign an authorization form, you do not have to sign it. If you do not sign the authorization, we cannot make the use or disclosure. If you do sign one, you may revoke it at any time unless we have already acted in reliance upon it. Revocations must be in writing. Send them to the office contact person named at the beginning of this notice.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

Although your health record is the physical property of Attention Homes, the information belongs to you. You have the right to:

1.Request a restriction on certain uses and disclosures of your health information as described above in this Notice. Although the client has the right to make such a request, please note that we are not required to agree to a requested restriction.

2. By written request to the Privacy Officer, inspect and obtain a copy of your health record except for psychotherapy notes, information compiled in reasonable anticipation of, or for use in, a civil, criminal or administrative action or proceeding, or clinical laboratory information access to which is prohibited by law.

3. Request amendment of your health information record. If you feel that health information in your record is incorrect or incomplete, you may ask that the information be amended. You have this right for as long as the information is maintained by Attention Homes. Your request must be in writing with the reason(s) supporting your request and submitted to Attention Homes’ Privacy Officer. Your request to amend your health record may be denied if:

· it is not in writing;

· it does not include a reason to support the request;

· the information was not created by a provider while you were a client at Attention Homes;

· the information is not part of the health record;

· the information is not part of the record which you would be permitted to inspect or copy;

· the information is accurate and complete.

Obtain an accounting of disclosures of your health information in the six years prior to your request. An accounting will not include disclosures for treatment, payment and health care operations described in this Notice or disclosures made pursuant to your written authorization.

Request confidential communications. You have the right to request that we contact you about health matters in a certain way or at a certain location.

Revoke your authorization to use or disclose health information except as to the extent that action has already been taken.

Obtain a paper copy of this Notice upon receipt.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with Attention Homes’ Privacy Officer or with the Secretary of the Department of Health and Human Services- Civil Rights Division. All complaints to Attention Homes’ Privacy Officer must be submitted in writing, describe how you believe your privacy rights were violated, and be delivered in person, via fax or U.S. Mail to Attention Homes’ Privacy Officer.

By signing this notice, I acknowledge that I have read this notice of Privacy Practices and understand how my personal health information may be used and disclosed and how I can get access to this information.

________________________________ _________________

Client Signature Date

________________________________ _________________

Personal Representative Date

_____________________________ _______________

Parent/Guardian Date