I. Who is Subject to This Notice

Paige Forrest, MD; dba Forrest Psychiatry

II. Our Responsibility

Your health information includes records that we create and obtain when we provide you care, such as a record of your symptoms, examination and test results, diagnoses, treatments, and referrals for further care. It also includes bills, insurance claims, or other payment information that we maintain related to your care.

The confidentiality of your personal health information is very important to us. You may be particularly concerned about the disclosure of information about your mental health treatment. We share those concerns and believe that a broad assurance of confidentiality is important to successful treatment. Reflecting this fact, there are in general more stringent confidentiality rules, under both federal and state law, applicable to records of mental health treatment than to records of other kinds of medical information.

This Notice describes how we handle your health information and your rights regarding this information. Generally speaking, we are required to maintain the privacy of your health information as required by law; provide you with this Notice of our duties and privacy practices regarding the health information about you that we collect and maintain; and follow the terms of our Notice that is currently in effect.

III. Contact Information

After reviewing this Notice, if you need further information or want to contact us for any reason regarding the handling of your health information, please direct any communications to the following contact person:

Paige Forrest, MD

1102 S. Braddock Ave, Suite 2 Pittsburgh, PA 15218

IV. Uses and Disclosures of Information

As we noted above, a broad assurance of confidentiality is important to successful treatment and mental health treatment records generally receive heightened protection against unauthorized disclosures. Additionally, the American Psychiatric Association’s Principles of Medical Ethics, which we follow, may require us to obtain your consent in some situations before we make certain disclosures of your personal health information in situations in which state and federal law might allow disclosure without your consent. However, federal and state law do permit us to use and disclose limited and specific personal health information without your authorization for certain treatment, payment, and health care operations (examples of which are below) and in certain other circumstances (discussed in Part V of this Notice). Please note that we cannot generally disclose psychotherapy notes and other detailed and personal information concerning your treatment without your specific, written consent. A fuller description of what psychotherapy notes are and the limitations on their disclosure is contained later in this Notice.

Examples of using or disclosing health information for treatment: A nurse takes your pulse and blood pressure, records it in the medical record, and informs your doctor of the results. As another example, if you needed emergency medical treatment, we could advise the physician treating you of the medications you were taking, as needed, so you could receive the treatment you needed.

Example of using or disclosing health information for payment: We submit a bill to your health insurer or HMO to receive payment for your care; the insurer asks for health information (for example, your diagnosis and what care we provided) in order to pay us. In such situations, we will disclose only the minimum amount of information necessary for this purpose which will, absent your specific written consent, include no more than the names of the staff providing your care; the dates, types, and costs of therapies or services provided; and a short description of the general purpose of each treatment session or service.

Example of using or disclosing health information for health care operations: In the course of providing treatment to patients, we may perform certain important functions such as training programs, credentialing, medical review, etc. In performing such functions, we may rely on certain other persons, referred to as business associates, to assist us in these tasks. We will share with our business associates only the minimum amount of personal health information necessary for them to assist us, and the business associates are, in turn, extremely limited in their ability to disclose the information provided to them.

V. Other Uses and Disclosures

In addition to uses and disclosures related to treatment, payment, and health care operations, we may also use and disclose your personal information without authorization for the following additional purposes:

Child Abuse: If you are a child and we reasonably conclude that you may have been the subject of abuse, we are required to report that information to various state officials. In so doing, we may disclose health information about you.

Business Associates: We may share health information about you with business associates who are performing services on our behalf. For example, we may contract with a company to service and maintain our computer systems or to do our billing. Our business associates are obligated by federal law to safeguard your health information. In addition, we will share with our business associates only the minimum amount of personal health information necessary for them to assist us.

Communicable Diseases/Death Certificates: We are required to notify the Pennsylvania Department of Health if we treat or examine a person with certain identified diseases, conditions, or infections. No psychiatric illnesses are currently reportable. Similarly, we may disclose health information about you to the Health Department to complete a death certificate. Coroners and Funeral Directors: We may disclose health information about you to a coroner if that information is pertinent to the coroner’s duties, such as identifying a decedent or determining the cause of death. We may also disclose health information to funeral directors to enable them to carry out their duties.

Food and Drug Administration (FDA): We may disclose health information about you to the FDA or to an entity regulated by the FDA, in order, for example, to report an adverse event or a defect related to a drug you are taking or a medical device you are using. Medical devices are rarely used in psychiatry but medications are.

Health Oversight: We may disclose health information about you for oversight activities authorized by law or to an authorized health oversight agency, such as the state Board of Medicine or the County Mental Health agency to facilitate its auditing, inspection, or investigation related to our provision of health care. Please note that psychotherapy notes,

which are discussed later in this Notice, can only be disclosed to an agency that is overseeing the mental health professional who wrote the psychotherapy notes.

Judicial or Administrative Proceedings: If you are subject to involuntary commitment and treatment, or are otherwise the subject of court proceedings under the Mental Health

Procedures Act, we may release information to a court or mental health review officer. We may also notify your County Mental Health Administrator, or persons designated by him or her, when you are receiving inpatient care. Additionally, we may disclose health information about you in the course of other judicial or administrative proceedings, such as a Workers’ Compensation proceeding, in accordance with our legal obligations. Normally, this can only be done in response to a subpoena. Under Pennsylvania law, a subpoena for your medical records usually cannot be issued without either your agreement (or that of your lawyer on your behalf) or a Court Order.

Law Enforcement: We may, in response to a warrant or subpoena, disclose health information about you to a law enforcement official for certain law enforcement purposes. For example, we may be required to assist law enforcement to locate someone such as a fugitive or material witness, or to provide other information pertinent to an investigation. We may also advise police authorities in the event that you are seen in a hospital and you have been wounded or injured, either by yourself or others, by use of a deadly weapon.

Treatment of Minors and Notification to Parents: If you are between ages 14-18 and have voluntarily admitted yourself for inpatient care, we are required to notify your parents, guardian, or person acting in loco parentis that you have done so and to explain to them the proposed treatment. If we cannot identify any person in those categories, we may notify the county child welfare agency. In addition, if you are an unemancipated minor under age 18, there may be other circumstances in which we will disclose health information about you to a parent, guardian, or other person acting in loco parentis. For example, we may need to do so when their consent is necessary for you to receive non-mental health medical treatment. The extent to which we will provide treatment information about you to parents, guardians, and persons acting in loco parentis depends on, among other things, your age and the need for the involvement of those persons in treatment. We will attempt to reach agreements between you and your parents, guardians, or persons acting in loco parentis on this issue.

Organ and Tissue Donation: We may disclose health information about you to organ procurement organizations or similar entities to facilitate organ, eye, or tissue donation and transplantation to which you, or those persons authorized to act on your behalf, have consented.

Personal Representative: If you are an adult or emancipated minor who has a legally-appointed guardian, we may disclose health information about you to that person as necessary to make decisions about your health care.

Public Safety/Threats to Third Parties: We are required to notify a third party if we conclude that you have made a bona fide threat of serious physical harm to an identifiable third person and have the intent and capacity to carry that out. Notification in that situation would be limited to information about the threat and as necessary to allow the person to respond to it.

Research: We may disclose health information without a written authorization if an Institutional Review Board (IRB) or authorized privacy board has reviewed the research project and determined that the information is necessary for the research and will be adequately safeguarded. Generally, you will have consented to participate in the research project but there may be limited circumstances, for example when the research involves a retrospective review of records, in which you will not have.

Required By Law: We have tried in this Notice to identify all of the circumstances in which we may be required to disclose health information about you. There may, however, be other

situations in which we will disclose information about you as required by federal, state, or other applicable law.

Any Other Use or Disclosure — Authorization Required: Other uses and disclosures besides those identified in this Notice will be made only as otherwise authorized by law or with your written authorization, which you may revoke except to the extent that information or action has already been taken in reliance of the authorization. For example, your authorization is required for the use and disclosure of most psychotherapy notes, as discussed below, for uses and disclosures for marketing purposes, including subsidized treatment communications, for the sale of your protected health information, and for other reasons that may not be described in this Notice. If you wish to revoke your authorization you may do so by submitting your request to us in writing (see section III above for contact information.)

VI. Your Health Information Rights

Under the law, you have certain rights regarding the health information that we collect and maintain about you.

Right to Request Restrictions: You may request that we restrict certain uses and disclosures of your health information for treatment, payment or health care operations as well as for disclosures to family members and certain others who may be involved in your care of the payment for your care. We are not, however, required to agree to a requested restriction unless it relates to disclosure to a health plan for a purpose other than treatment and it pertains solely to a health care item or service for which you paid for in full, out of your own pocket, or is otherwise required by law. If we do agree to your requested restriction, we will comply with your request except as needed to provide you emergency treatment.

Right to Request Communication by Alternative Means: You may request that we communicate with you by alternative means, such as making records available for pick-up, or mailing them to you at an alternative address, such as a P.O. Box. We will accommodate reasonable requests for such confidential communications.

Right of Access to Personal Health Information: You may request to review, or to receive a copy of, the health information about you that is maintained in our files and the files of our business associates (if applicable). In most cases, we may charge a reasonable fee for our costs in copying and mailing your requested information. You may request an electronic record of information that we maintain as an electronic health record. We may charge you for the reasonable preparation of the electronic record as permitted by law. Please note that we may deny you access to limited portions of the information we maintain if we determine that the requested information falls under certain permitted exceptions. For example, we may deny access to information that would constitute a substantial detriment to your treatment, or that would reveal the identity of persons or breach the trust or confidentiality of persons who have provided information upon an agreement to maintain their confidentiality. We may also deny access when we determine that access may endanger the life or physical safety of either you or another person. If we are unable to satisfy your request, we will tell you in writing the reason for the denial and your right, if any, to request a review of the decision.

Right to Request Amendment: You may request that we amend the health information about you that is maintained in our files and the files of our business associates (if applicable). Your request must explain why you believe our records about you are incorrect, or otherwise require amendment. If we are unable to satisfy your request, we will tell you in writing the reason for the denial and tell you how you may contest the decision, including your right to submit a statement (of reasonable length) disagreeing with the decision. This statement will be added to your records.

Right to an Accounting of Disclosures: You may request a list of our disclosures of your health information. This list, known as an accounting of disclosures, will not include certain disclosures,

such as those made for treatment, payment, or health care operations. We will provide you the accounting free of charge; however, if you request more than one accounting in any 12 month period, we may impose a reasonable, cost-based fee for any subsequent request. Your request should indicate the period of time in which you are interested (for example, “from May 1, 2003 to June 1, 2003′′). We will be unable to provide you an accounting for any disclosures made before April 14, 2003, or for a period of longer than six years.

Right to a Paper Copy of this Notice: You may request a paper copy of this Notice, even if you have agreed to receive this Notice electronically. You may request such a copy at any time. Right to be Notified of a Breach of your Unsecured Protected Health Information: We will notify you in the event of an unauthorized acquisition, access, use or disclosure of your unsecured protected health information, subject to certain exception provided by law.

In order to exercise any of your rights described above, you must submit your request in writing to our contact person (see Section III above for contact information). If you have questions about your rights, please speak with our contact person, who is available in person or by phone or e-mail, during normal office hours.

VII. To Request Information or File a Complaint

If you believe your privacy rights have been violated, you may file a written complaint by mailing it or delivering it to our contact person (see Section III above). You may complain to the Secretary of Health and Human Services (HHS) by writing to Office for Civil Rights, U.S.

Department of Health and Human Services 150 S. Independence Mall West, Suite 372, Public

Ledger Building, Philadelphia PA 19106-9111; by calling 800/368-1019 (main line),

215/861-4431 (fax), or 800/537-7697 (TDD). We cannot, and will not, make you waive your right to file a complaint as a condition of receiving care from us, or penalize you for filing a complaint.

VIII. Revisions to this Notice

We reserve the right to amend the terms of this Notice. If this Notice is revised, the amended terms shall apply to all health information that we maintain, including information about you collected or obtained before the effective date of the revised Notice. If the revisions reflect a material change to the use and disclosure of your information, your rights regarding such information, our legal duties, or other privacy practices described in the Notice, we will promptly distribute the revised Notice, post it in the waiting area(s) of our office, and make copies available to our patients and others, and post it on our website. IX. Effective Date This Notice was amended effective April 7, 2016