Cortica Notice of Privacy Practices

Notice of Privacy Practices TO PROTECT THE PRIVACY OF YOUR HEALTH INFORMATION

This page provides a summary of how health information about you may be used and disclosed and how you can get access to this information.

Cortica is committed to protecting medical, mental health, and personal information regarding you and your family. We are required by law to ensure the privacy of health information, provide you with information about our legal duties and privacy practices, and inform you of your rights and the ways in which we may use health information and disclose it to other entities and persons.

You have the right to: • • • • • • • •

Get a copy of your paper or electronic medical record Correct your paper or electronic medical record Request confidential communication Ask us to limit the information we share Get a list of those with whom we’ve shared your information Get a copy of this privacy notice Choose someone to act for you File a complaint if you believe your privacy rights have been violated

The following list describes ways we may use and disclose health information. We may use and share your information: For treatment. We may use health information to provide medical services and disclose health information to doctors, therapists, nurses, technicians, or other Cortica personnel involved in taking care of you or those relatives for whom you are a caregiver (e.g., your children).

For payment. We may use or disclose health information so that treatment and services you receive from Cortica may be billed and payment collected from you, an insurance company, or other designated third party.

For health care operations. We may use or disclose health information in support of our business operations. This includes ensuring our services' quality and safety, reviewing progress against a care plan, and general support of our therapy models. We may also use and disclose your health information to an outside company that performs services for Cortica. These outside companies are Cortica's contractual “business associates” and are required by law to keep your health information confidential.

Appointment reminders. We may inform you that you or your family member have an appointment with Cortica. Contact methods can include emails, SMS (texting), phone calls, emails, and other similar services.

To assist with public health and safety issues.

For research. Cortica is routinely involved in research studies with other leading providers of neurologic care services. We may disclose health information about you or your family member for research purposes, subject to the confidentiality provisions of state and federal law. All research projects involving patients are approved by an internal review board and performed only upon express consent of the patient or of-age consenting family member.

As required by law. We will disclose health information about you when required to do so by federal or state law.

To respond to organ and tissue donation requests. This applies only if you or a patient you care for is a registered organ donor.

When working with a medical examiner or funeral director.

To address workers’ compensation, law enforcement, and other government requests.

In response to lawsuits or other legal actions. We may disclose health information to courts, attorneys, and court employees in the course of conservatorship, writs and certain other judicial or administrative proceedings. We may also disclose Health Information about you in response to a court or administrative order, or in response to a subpoena, discovery request, warrant, or other lawful process.

Other uses. Other uses and disclosures of health information not covered by this notice will be made only with your written authorization. If you authorize us to use or disclose your health information, you may revoke that authorization, in writing, at any time. However, the revocation will not be effective for information that we have already used and disclosed in reliance on the authorization.

Psychotherapy notes. Psychotherapy notes are notes recorded by a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session. Psychotherapy notes have additional protections under federal law and most uses or disclosures of psychotherapy require your written authorization.

Changes to Cortica’s Privacy Practices We reserve the right to change Cortica’s privacy practices and this document. We reserve the right to make the revised or changed document effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current document. At any time, you may request a copy of the current Notice in effect.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

This document is to be signed by a person legally responsible for the patient’s medical decisions relative to treatment.

By signing this document I acknowledge that I have received a complete copy of Cortica’s Privacy Practices describing how medical and health information about me may be used and disclosed. I understand that if I have questions or complaints, I may contact the office at 858- 304-6440 and speak with the privacy official.

By checking below, you are attesting you have read and understand this information I agree

Cortica Policies and Permissions INFORMED CONSENT FOR ASSESSMENT AND TREATMENT

I understand that as a patient of Cortica, I or my child am/is eligible to receive a range of services.

The type and extent of services recommended will be determined following an initial assessment and thorough discussion with me. The goal of the assessment is to determine the best course of treatment. Typically, the assessment process can range between 1-2 months.

On behalf of myself or my minor child or other patient named below, I acknowledge and consent to the statements made in this form.

Consent to health care services: I am requesting that health care services be provided to me or my minor child or the patient named below at Cortica, Inc. I voluntarily consent to all medical treatment and health care-related services that the team at Cortica considers to be necessary for me (or the patient named below). These services may include assessment, diagnostic, therapeutic, imaging, and laboratory services.

I understand that all information shared with Cortica is confidential and protected by the laws set forth under the Health Information Portability and Accountability Act (HIPAA). During the assessment and treatment, it may be necessary for Cortica’s health care provider(s) to communicate and collaborate with other health care provider(s). While written authorization will not be requested, I understand that Cortica’s health care provider(s) will discuss all communications with me. In all other circumstances, consent to release information is given through written authorization. Verbal consent for limited release of information may be necessary in special circumstances.

I further understand that there are specific and limited exceptions to this confidentiality which include the following: When there is risk of imminent danger to me or to another person, the supervisor is ethically bound to take necessary steps to prevent such danger.

When there is suspicion that a child is being sexually or physically abused or is at risk of such abuse, the supervisor is legally required to take steps to protect the child, and to inform the proper authorities.

When a valid court order is issued for medical records, the supervisor and the agency are bound by law to comply with such requests.

I understand that a range of professionals, some of whom are in training, provide Cortica services.

All professionals-in-training are supervised by licensed or certified teammates. If I have any questions regarding this consent form or about the assessment and/or treatment process, I may discuss them with the clinical supervisor or the office.

I have read and understand the above. I consent to participate in assessment and treatment offered to me by Cortica. I understand that I may stop treatment at any time.

If I have any questions regarding this consent form or about the assessment and/or treatment process, I may discuss them with the supervisor or the office.

Communication Policy

In compliance with HIPAA and other security standards, Cortica sends all patient communication over encrypted channels. This includes email. When sending an email to a patient, Cortica uses a secure encrypted portal. In rare instances when patients are unable to access email through the encrypted portal, Cortica may send an email to a patient’s personal email address. This email may contain personal health information (PHI) and should not be forwarded or shared without patient consent.

I have received Cortica’s Notice of Privacy Practices. The Notice of Privacy Practices explains how Cortica may use and disclose confidential health information that identifies me (or the belownamed patient). I consent to let Cortica use and disclose health information about me (or the below-named patient) as described in the Notice of Privacy Practices.

I consent to receive, on the cellular phone and/or other telephone number(s) that are provided to Cortica, text messages and/or telephone calls or other communications using live, artificial, or prerecorded voices, automatic telephone dialing systems, or any other computer-aided technologies from Cortica and its affiliates, clinical providers, business associates, billing agencies, and any third parties that act on Cortica’s behalf. Such text messages and/or telephone calls may be related to any purpose, including those related to my account and/or the care rendered. I understand this consent to communications is not required to receive services from Cortica or any of the other authorized callers and that data usage and other charges may apply. I may revoke this consent to these communications at any time.

Clinician Assignments Clinicians are assigned to cases based on availability, qualifications, expertise, and each client's unique therapeutic needs. Cortica strictly prohibits any form of discrimination based on sex, culture, race, religion, or any other protected characteristic including physical appearance.

General Rules of Conduct Family members, guardians, and other caretakers agree to:

Participate fully and honestly in treatment and services activities Refrain from the use of any negative, abusive, vulgar, obscene, or demeaning language • Refrain from any harassing, aggressive, or threatening conduct towards others, and • Respect the property rights of others • •

I understand that violating Cortica’s rules of conduct may prevent Cortica from providing appropriate care to my child and/or family and may lead to a discharge from all Cortica services.

Notice of Shared Custody It is your responsibility to notify us of any shared custody arrangements including providing court orders and other pertinent documentation.

Notice of Legal Guardianship or Conservatorship It is your responsibility to provide documentation of guardianship or conservatorship, for clients 18 years or older who may have a legal guardian or person responsible for their care.

Cortica Cancellation Policy We believe that your child’s success begins with the consistency of treatment. Therefore, we are committed to doing our best to be here for your child on a consistent basis, and we trust that you will place the utmost importance on maintaining your appointments.

Available appointments are in high demand, and your early cancellation will give another family the possibility to have access to timely care. If you need to cancel an appointment, we ask that you give us 72 hours’ notice by calling the center.

If you need to cancel a Monday appointment over the weekend, please email scheduling@corticacare.com which will allow us to offer this time slot to another client who needs care.

Please note the following: If you do not give us 72 hours’ notice, you will be charged a $50 service charge.

This fee will be charged irrespective of the number of sessions canceled that day.

• If you fail to show up for a scheduled appointment and do not call to cancel, you will be charged a $100 service charge. Two consecutive no-shows may result in automatic removal from the regular schedule.

• Our team will provide an opportunity to reschedule your child's session as their therapists' schedules allow.

• If you arrive more than 10 minutes late for your appointment, your session may be cancelled, and you will be charged a $50 service fee. If you arrive late for a therapy •

session (no more than 10 minutes late), we will still end the session at the scheduled time to allow our therapist to transition to their next appointment.

• These charges cannot be billed to insurance, and we will charge the cancellation fee to the credit card on file for your account.

Please be aware that multiple cancellations and late arrivals have a detrimental effect on the consistency of your child’s progress. Late pick-ups are also a challenge for our team, as our therapists are typically transitioning directly into another session. If a monthly attendance rate of at least 80% is not maintained, Cortica reserves the right to offer those recurring appointment slots to another family.

By checking below, you are attesting you have read and understand this information I agree Telehealth/Telemedicine Informed Consent I understand that Cortica may provide certain services by remote telehealth technology and I consent to engaging in telemedicine at Cortica as part of my therapy services. I understand that “telemedicine” includes the practice of health care delivery, assessment, diagnosis, consultation, treatment, transfer of medical data, and psychoeducation using interactive audio, video, or data communications. Such telehealth services involve a health provider who is at a site remote from my location at the time of the service, and, as such, telehealth often involves the transmission of video, audio, images, and other types of data. Further, I understand that I may have to travel to see a health provider in-person for certain diagnosis and treatment matters.

Technology: I understand that I may need to download an application and/or software to use this platform. I also need to have a broadband internet connection or a smart phone device with a good cellular connection at home or at the location deemed appropriate for services.

Scheduling: I understand that scheduling is conducted through Cortica and is based on my provider’s normal clinic hours. Telemedicine appointments are considered outpatient services and not intended as a substitute for emergency or crisis services. Crisis or mental health emergencies should be directed to the local county crisis line or by dialing 911.

Confidentiality: The laws that protect the confidentiality of my medical information also apply to telemedicine. As such, I understand that the information disclosed by me during my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality including, but not limited to: Reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and situations where I make my mental or emotional state an issue in a legal proceeding. Cortica’s telemedicine platform is HIPAA-compliant to protect my privacy and confidentiality. I understand that I have the following rights with respect to telemedicine: •

I have the right to withdraw my consent at any time.

I understand that there are risks and consequences associated with telemedicine including, but not limited to the possibility, despite reasonable efforts on the part of my provider, that the transmission of my medical information could be disrupted or distorted by technical failures.

•

I understand that my child and family may benefit from telemedicine but that results cannot be guaranteed or assured.

•

Recording: I hereby consent and grant to Cortica the right and authority to photograph and/or record me or the below-named patient, which could occur in connection with my diagnosis and treatment, and I agree that upon creation such images and/or recordings are owned by Cortica. I understand that I have the right to request cessation of recording or filming at any time. I agree to release and forever discharge Cortica, its agents, officers, and employees from all claims arising out of or in connection with the use of these images and/or recordings including, but not limited to, any claims for invasion of privacy, right to publicity or defamation.

I give permission for telehealth video recordings to be used for clinical consultation with other professional(s), for review with my child, myself and/or my family, and for training purposes for Cortica staff.

I understand that I may withdraw recording permission at any time. My willingness to consent to this recording does not affect participation in the therapy program or any of the services we (child, parent, family, or authorized representative) may receive.

By checking below, you are attesting you have read and understand this information I agree Parent Agreement for In-Center Services Cortica requires that all minor patients under the age of 18 be accompanied by a parent, guardian, or other designated adult over the age of 18 for both drop-off and pick-up from Cortica sessions taking place at our centers.

I agree Patient Assignment of Benefits and Financial Responsibility Insurance Release & Assignment of Benefits I authorize the release of any medical information necessary to process insurance claims for services provided to me or my dependents by Cortica Healthcare, Inc., or Cortica Behavioral Healthcare Inc. I also authorize payment of benefits directly to Cortica Healthcare, Inc. or Cortica Behavioral Healthcare Inc. for services provided to my dependents or me.

I understand that this authorization may not result in full payment by my insurance plan for the charges incurred and I agree that I am financially responsible to make payment in full on remaining patient balances should my insurance plan determine the services I received are not covered.

Insurance Cortica participates in many insurance plans. If you are not insured by a plan, we do business with, or do not have an up-to‐date insurance card, payment in full is expected at each visit. When you provide us with current and complete information, we bill primary and secondary insurances if we are a participating provider with that plan.

Please contact your insurance company with any questions you may have regarding your coverage. We will provide you with an estimated cost of services based on insurance benefits.

This is only an estimate and can vary when claims process by your insurance. If you have a change in your insurance, it is your responsibility to inform us in a timely manner to avoid the potential of being responsible for charges.

Referral I understand that if my insurance requires a referral from my Primary Care Provider for specialist services and if I do not have the referral at the time of the appointment, and I still choose to receive the services without the required referral, it will be my responsibility to contact my primary care provider’s office the same day and obtain the necessary referral, dated for the date of the service.

I also accept full financial responsibility for all charges incurred for services received on the day of service if my insurance carrier denies the claim(s) for lack of and/or invalid referral.

If I am unable or unwilling to obtain a referral, I will be responsible for payment of services at the self-pay price.

Payment I accept financial responsibility for payment of all services and products received. All copayments, co-insurance and deductibles must be paid at the time of service or within 10 days of receiving a statement from Cortica. My share of the cost is part of my contract with my insurance company, and I may pay by check or with credit card.

By checking below, you are attesting you have read and understand Cortica Policies and Permissions I agree California Notice Pursuant (AB) 1278 The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.

For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided here. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public.