School Bridge, LLC 1489 Chain Bridge Road, #203, McLean, Virginia 22101 www.testingld.com

Privacy Notice 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. School Bridge, LLC. (the PRACTICE) is required by the Health Insurance Portability and Accountability Act (HIPAA), a federal law, to maintain the privacy of your health information and to provide you with this notice. The PRACTICE is required to meet all procedures and standards defined in this notice. Your

Privacy is Important The PRACTICE understands your privacy is important. The PRACTICE will handle information about you only as allowed by federal and state law and PRACTICE policy. If at any time you believe your privacy rights have been violated, you may verbally or in writing contact: 1. PRACTICE Privacy Officer 2. United States Secretary of Health and Human Services Addresses and phone numbers to use for this contact are listed at the end of this notice. You will not suffer a change in your services or retaliation for filing a complaint. Each time you receive services from the PRACTICE, the evaluator makes a record of the visit. Typically, this record contains your assessment, service plan, progress notes, diagnoses, and plan for future care or recommended treatment.

Your Federally Defined Rights under HIPAA. There are several rights concerning your health information in the record that the PRACTICE wants you to be aware of 1. You have the right to request access to your record in order to inspect, copy, amend, or correct it. This right is not absolute. In certain situations, such as if access would cause harm, the PRACTICE can deny access. You must make this request in writing to the evaluator. 2. You have the right to receive at any time accounting of the PRACTICE's disclosure of your record. You have the right to receive information from the PRACTICE through the means you prefer (e.g., telephone, mail 3. You have the right to request a restriction with regard to the use or disclosure of your record. This request will be given serious consideration and you will be informed promptly whether the PRACTICE will be able to use the restriction and still offer effective services, receive payment, and maintain operations. Legally the PRACTICE is not required to abide by any restrictions you request.

Use and Disclosure of Your Information The PRACTICE uses and discloses necessary information about you internally and with business associates in order to provide service, receive payment for service provided, and conduct day-to-day business practices. For example: In order effectively to provide service, the evaluator may consult with or seek supervision from other service providers associated with the PRACTICE. During those consultations or supervisions, health information about you the client, and family may be shared. In order to receive payment for services provided, your health information may be sent to those companies or groups responsible for payment, or that you designate as your third-party payor. In addition, the PRACTICE sends a monthly bill to the responsible party identified by you and noted on your financial form. Patient bills outstanding for more than (3) three months will be submitted by School Bridge, LLC www.testingld.com the PRACTICE to a collection agency or attorney for litigation. In day-to- day business practices, trained staff may handle your physical records in order to have the record assembled and available for review by your evaluator and to file documentation. Certain data elements are entered into the PRACTICE's computer system.

Specific Circumstances for Disclosure. The PRACTICE is allowed by federal and state law in certain circumstances to disclose specific health information about you without your consent, authorization, or opportunity to agree or object. These specific circumstances may include 1. As required by law and limited to the relevant requirements of law 2. For public health activities - to the Health Department to prevent or control disease 3. On behalf of children or incapacitated adults who are victims of abuse, neglect, or exploitation - to report as required by law any suspicion of abuse, neglect, or exploitation 4. Judicial and administrative proceedings - in response to a court order 5. Law enforcement purposes - to report criminal conduct that occurs on PRACTICE property Dead persons - to assist coroners and medical examiners to identify a deceased person or to determine the cause of death 6. To avert a serious threat to health and safety - to yourself or someone else 7. Specialized government functions - for protection of the President of the United States 8. Workers' Compensation - to comply with laws related to Worker's Compensation A more detailed explanation of all situations allowed by federal and state law is available upon request. Other Uses and Disclosures of Your Information by Authorization Only When you request information to be disclosed to another party or to yourself, the PRACTICE will respond within federal and state law. The PRACTICE is required to obtain your authorization to use or disclose your protected health information for any reason other than treatment, payment, health care operations, and those specific circumstances outlined previously. The PRACTICE uses an Authorization to Release and Obtain Confidential Information form that specifically states what information about you will be given to whom and for what purpose. You or your legal representative signs the form. You may revoke the signed authorization at any time, except to the extent that action has been taken in reliance on it, by giving your therapist/psychologist/case manager a written statement to that effect.

Changes to Privacy Practices. The PRACTICE reserves the right to change any of its privacy policies and related practices at any time and to make the change effective for all health information that the PRACTICE maintains, as allowed by federal and state law. You will receive notice of changes either by mail, discussion with a PRACTICE representative, electronically, or a combination of all three. School Bridge, LLC www.testingld.com If you would like additional information concerning the privacy policy or the federal or state laws pertaining to privacy, please contact WPA, PC Privacy Officer United States Department of Health and Human Services William J. Stejskal, Ph.D. Office of the Secretary 4320 Prince William Parkway 200 Independence Avenue, S.W. Woodbridge, VA 22192 Washington, D.C. 202-619- 0257 877-696-6775 (toll-free

School Bridge, LLC 1489 Chain Bridge Road, #203, McLean, Virginia 22101 www.testingld.com

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