Notice of Privacy Practices

IPM - Employee Assistance Program

Effective Date: April 14, 2003

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.

The information in this notice also applies to others covered under your EAP, such as your spouse or children.

EAP Responsibilities
The EAP is required by law to maintain the privacy of your health information and to provide you with notice of our legal duties and a description of our privacy practices. The EAP will abide by the terms of this notice.

Uses of Your Health Information
The EAP is required to use or disclose your health information:

• To the Secretary of the Department of Health and Human Services (DHHS), if necessary, to help ensure that your privacy is protected;
• When required by law.

The EAP is permitted to use and disclose your health information for:

• Treatment purposes, which include, but are not limited to, the provision, coordination, or management of health care. An example would be the EAP's, or its business associate's, disclosure to an EAP counselor your phone number and a summary description of the issue for referral purposes
• Payment purposes, which include, but are not limited to, fulfilling its responsibility for coverage and provision of benefits. An example would be the EAP's, or its business associate's, exchanging information with a provider to facilitate payment for an EAP counseling session.
• Health care operations, which include, but are not limited to, evaluating EAP performance, customer service, and other administrative activities. Examples would be the plan's, or its business associate's, evaluating information about EAP utilization, projecting future EAP costs, or evaluating the payment process.

The EAP may use or disclose your health information for the following purposes under limited circumstances. Please note that these are examples and do not include each particular use or disclosure.

• Providing your health information to you or a person who may legally act for you (personal representative),
• Contacting you with information about treatment alternatives or other health-related benefits and services,
• Disclosing information to the plan sponsor of the EAP as permitted or required by the plan documents or as required by law,
• To business associates with which the EAP has a contract so that the business associate may perform the agreed upon service(s) for the plan,
• Public health activities,
• Health oversight agencies for oversight activities authorized by law, including audits and investigations,
• Judicial and administrative proceedings,
• Law enforcement purposes,
• To avert a serious threat to health or safety,
• For specialized government functions, such as national security and intelligence activities, military service, etc.,
• Workers' compensation or other similar programs,
• To a governmental authority, to the extent required by law, if the EAP reasonably believes you are a victim of abuse, neglect, or domestic violence,
• To researchers when their research has been approved by an Institutional Review Board that has reviewed the research proposal and established protocols to ensure the privacy of your information.

State-Specific Requirements: Some states have separate privacy laws that may apply additional legal requirements. If the State privacy laws are contrary to but more stringent than Federal privacy laws, the State law preempts such Federal privacy laws to the extent such State law is not otherwise preempted by ERISA.

Other Uses of Health Information
Other uses and disclosures of medical information not covered by this notice or the laws that apply to the EAP will be made only with your written permission. If you provide the EAP permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, the plan will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that the plan is unable to take back any disclosures it has already made with your permission, and that the EAP is required to retain its records.

Your Health Information Rights
By law, you have the right to:

• Request to inspect and obtain a copy of your health information maintained by the EAP. The EAP may deny your request to inspect and copy in certain very limited circumstances. If you are denied access, you may request that the denial be reviewed in some cases. A person other than the person who denied your request will conduct the review. The EAP will provide or deny access in accordance with the determination of the reviewer.
• Request the plan to amend your health information, if you feel that the health information the EAP has about you is incorrect or incomplete. If the EAP disagrees, you will be notified of the reason for denial, and you may submit a statement of disagreement to be added to your personal health information. The EAP may prepare a rebuttal to your statement.
• Request an accounting of disclosures. This is a listing of disclosures that the plan makes of your health information after April 14, 2003. This listing would not include disclosures for treatment, payment or health care operations; disclosures made to you or your personal representative; disclosures to persons involved in your care or payment for that care, and disclosures you authorize. The right to receive an accounting is subject to certain restrictions.
• Request a restriction or limitation on how the EAP uses your health information for certain purposes. The EAP is not required to agree to your request.
• Request confidential communications. You may request that the EAP communicate with you in a different manner or at a different place if you clearly state that the disclosure of all or part of the information could endanger you. The request must be submitted in writing and include an alternate address or other method of contact. The EAP reserves the right to contact you by other means and at other locations if you fail to respond to any communication from the plan that requires a response.
• Obtain a paper copy of this notice. You may ask the EAP to provide you a paper copy of this notice at any time. You may also print or view a copy of the notice currently in effect on the web at www.ipm-eap.com.com.

To exercise your rights under this notice and for further information about matters covered by this notice, please contact the EAP Office and ask to speak to Mike Ashworth, Ph.D. The office number is (888) 600-4327.

Complaints
If you believe your privacy rights have been violated, you may file a complaint with the EAP. All complaints must be submitted in writing to the following address:

IPM Employee Assistance Program
4001 West 15^th St., Suite 465
Plano, TX 75093

You may also file a complaint with the Secretary of the Department of Health and Human Services.

You will not be penalized for filing a complaint.

Changes to This Notice
The EAP plan reserves the right to revise its practices and this notice. The revised notice will be effective for information the plan already has about you as well as any information it creates, receives, or maintains in the future. The current notice in effect will be posted at www.ipm-eap.com. Additionally, you will be mailed a new notice within 60 days of any material change to the notice.