Effective April 14, 2003

SUMMARY

This notice describes how Health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

• To perform health related services, obtain payment, or carry out our operations.
• To conduct research approved by an Institutional Review Board, a legally authorized committee that protects participants' rights and oversees research.
• As otherwise required or allowed by law, or with your written authorization.

Any time you wish to exercise your privacy rights please refer to the Your rights regarding your health information section of this policy regarding your rights about your health information.

Free & Clear, Inc. is committed to the highest quality services and products. Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), because our services are related to your health we must take steps to protect the privacy of the information you provide to us or that we create on your behalf. This information may include both health information and personal information such as your name, social security number, address, and phone number.

Although our services are related to your health, Free & Clear, Inc. is not a medical treatment provider and our staff cannot provide medical treatment, diagnosis, or monitoring. Free & Clear, Inc. programs should not be relied upon as a substitute for professional medical advice. Free & Clear, Inc. programs are intended to assist you with personal health improvement efforts through coaching, education, and instruction. Always continue to seek the advice of your doctor with any questions you may have regarding your medical conditions.

• Protect the privacy of your health information. All employees and associates of Free & Clear, Inc. are required to maintain the confidentiality of health information and receive appropriate privacy training.
• Provide you with this Notice of Privacy Practices explaining our duties and practices regarding your health information and to follow the practices and procedure set forth in this Notice.
• One-way we will ensure we protect your privacy is to adhere to the standards of privacy and security set out by the Secretary of Human Services. This Notice describes our practices and that of all employees, staff, and other members of our workforce.

Free & Clear, Inc. uses and shares health information in a number of ways connected to our health related services, payment, and our operations. Some examples of how we may use or share your health information without your authorization are listed below.

            Health related services.

• To our employees or other members of our workforce involved with providing you your health related services.

• To other health care providers in the community treating you who are not on our staff.

            Payment purposes.

• To bill or administer your health benefits policy or contract.

• To other organizations and providers for payment activities unless disclosure is prohibited by law.

            Health care related operations.

• To administer and support our business activities, we give information to organizations that will survey on our behalf for satisfaction, quality, and/or program outcomes, or those of other health care organizations as allowed by law including providers and plans.

• To other individuals such as consultants and attorneys and organizations that help us with our business activities. If we share your health information with other organizations for these purposes, they must agree to protect your privacy.

We may use and share your health information for research projects that have been approved by an Institutional Review Board (IRB), a legally authorized committee that protects participants' rights and oversees research. For example:

• When an IRB ensures that the need to use your health information without your authorization is justified and steps are taken to ensure only limited use of such information, we may use and share it for a research project without your authorization.
• When the IRB approves the use and sharing of information, or you authorize the use and sharing of information for a research project, your information may be shared with other institutions.
• In all other cases, we must obtain your authorization to use your information for a research project.

Your health information may also be used to contact you. For example, we may contact you to remind that you have an appointment with us. These reminders may be made by postcard, phone, or voicemail.

We may use or share your health information to enhance health care related services, protect safety, safeguard public health, and when otherwise allowed by law. For example, we may provide information to:

• Public health authorities for health surveillance, to investigate or track problems with prescription drugs and medical devices (U.S. Food and Drug Administration).
• Government entities authorized to receive reports when we suspect abuse, neglect, or domestic violence.
• Health care oversight agencies for certain activities such as audits, examinations, investigations, inspections, and licensures.
• Courts when ordered or for lawful subpoena.
• Law enforcement when required or allowed by law.
• Coroners, medical examiners, and funeral directors.
• Correctional facilities, if we are providing health related services to you while you are incarcerated.
• Government officials as required for specifically identified government functions.

• Disclosure to family and friends. Unless you object, your health care provider will use their professional judgment to provide relevant health information to a family member, friend, or other person you indicate has an active interest in your care.

• Except in the situations listed in the sections above, we will use and share your health information only with your written authorization.
• You may revoke such authorization in writing at any time. If you revoke your authorization, we will no longer use or disclose your information for the purposes covered by your authorization. You must understand, however, that we are unable to take back any disclosures we have already made in reliance on your authorization.

In some situations, federal and state laws provide special protections for specific kinds of health information and require authorization from you before we can share protected health information. In these situations, we will contact you for the necessary authorization.

You have specific rights regarding the use and disclosure of your health information. You have the right to:

• Request to receive and inspect copies. In most cases, you have the right to look at or order a copy of your health related record by using an Authorization to Release Health Information Form provided by calling us at 1-866-QUIT-4-LIFE (784-8454). You may be charged reasonable fees for copies provided.
• Request an amendment. If you believe that information is incorrect or missing, you have the right to request in writing that we correct the existing information or add the missing information. In your request, you must give a reason for the change. We are not required to amend the record, but a copy of your request will be added to the record if you direct us to file it.
• Request to know about disclosures. You have the right to request in writing a list of certain disclosures of your health information since April 14, 2003. The accounting of disclosures will not include disclosures to those related to providing treatment, payment, health care operations, or when you have authorized the disclosure. You may receive one list per year at no charge. You will be charged a processing fee for each additional request within the same twelve-month period.
• Request restricted use. You have the right to ask us in writing to restrict certain uses and disclosures of your health information. We are not required to grant the request but we will comply with any request we grant.
• Request how we communicate. You have the right to request in writing that we communicate with you by another means. For example, you may ask us to contact you at work or at a different address. We are not required to grant the request, but we will comply with any request we grant.
• Make a complaint. If you think that we may have violated your privacy rights or you disagree with a decision we made about access to your health information, you may file a written complaint with our Privacy Office. You will not be penalized or retaliated against if you file a complaint.
• Right to receive a copy of this Notice. You have the right to receive a paper copy of this Notice, even if you have already received it previously.

Free & Clear, Inc.
Attn: Free & Clear Privacy Officer
999 3rd Avenue, Suite 2100
Seattle, Washington 98104
1.866.QUIT.4.LIFE (1.866.784.8454)
TTY: 1-877-777-6534

Office for Civil Rights, Region X
U.S. Department of Health and Human Services
2201 6th Avenue, Mailstop RX-11
Seattle, Washington 98121-1831
206-615-2297

Free & Clear, Inc. may change the terms of this Notice at any time. The revised Notice would apply to all health information that we maintain. We post our current Notice in our web site (www.freeclear.com) and at our facilities. If you have any questions about this Notice or would like an additional copy, please contact the Privacy Officer at 1-866-QUIT-4-LIFE (784-8454).