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Date:______________________________________________ Referred by:_____________________________________________

PATIENT INFORMATION - Please fill out completely.

Last Name:___________________________________ First Name:_________________________________M.I._______________ Street Address______________________________________________________________________________________________ City:__________________________________ State:______________ Zip:___________________Gender (Circ e!: Fema e" Ma e #$me %&$ne:________________________'ffice %&$ne:________________________ Ce :_______________________________ (mai :_____________________________________Date $f )irt&:_________________________ SS*:_______________________ Marita Stat+s: (circ e! Sin, e " Married " Di-$rced " .id$/ed " Separated " %artnered " 't&er _______________________________ (mp $yer"Sc&$$ Name and p&$ne n+mber:_______________________________________________________________________ Sp$+se0s Name and daytime p&$ne n+mber:_______________________________________________________________________ If patient is in a ,r$+p $r pers$na care &$me p ease pr$-ide t&e NAME OF FACILITY/CONTACT PERSON/P ONE N!M"ER be $/: __________________________________________________________________________________________________________

Respo#si$le Pa%ty& P%o'i(e i#fo o# )*o is %espo#si$le fo% payi#+ fo% t*e se%'ice ,if (iffe%e#t f%om patie#tName:_______________________________________________________________________ SS*:__________________________ Address:___________________________________________________________________________ %&$ne:__________________ Re ati$ns&ip t$ %atient1_______________________________________________________________________________________ Eme%+e#cy Co#tact& (Name"n+mber"re ati$n! ____________________________________________________________________

..I#su%a#ce Policy

ol(e%/s I#fo%matio#& ,Please p%o'i(e i#su%a#ce ca%( fo% copyi#+-

Name $f %$ icy #$ der:________________________________________________ ID*: ___________________________________ %$ icy #$ der2s date $f birt&:_______________________ SS*:___________________________ Re ati$ns&ip t$ %t:_____________ Name $f Ins+rance C$:________________________________________________________________________________________ %&$ne n+mber and address:_____________________________________________________________________________________ (mp $yer $f Ins+red:__________________________________________________ Gr$+p *:________________________________ Confidentiality: Your patient records are strictly confidential. For this reason, no information concerning you as a patient is released without your written consent. Disclosure of information to anyone such as another doctor, an attorney and/or a family member must be requested by written authorization by the patient. In an emergency situation when you, the patient, are at imminent ris of death or serious medical consequence, !astern "tlanta #eha$ioral %ealth &!"#%' will release minimal, critically rele$ant information to assist in pre$enting dire medical consequences that may result if that rele$ant information is not released. In the case of a minor, their legal guardian must sign the authorization. (he physician is legally bound to brea doctor)patient confidentiality in cases of threat of harm to self or others and in reports of child or geriatric abuse. 1353 Jennings Mill Rd Suite C Box 7, Bogart GA 30622 706-357-5 67 !""i#e $$$ 706-357-5 6% &ax


*e are happy to pro$ide you with this list of your rights as defined by the "merican +edical "ssociation: 3N$n Discriminati$n 3%ri-acy 3Inf$rmati$n ab$+t y$+r dia,n$sis 34&ird pers$n present d+rin, treatment pr$,n$sis and treatment p an 3Identificati$n $f pers$n pr$-idin, ser-ice 35$ +ntary c$nsent t$ treatment 3Acti-e participati$n in decisi$n ma6in, ab$+t y$+r 3Appr$7imate $-era c$st and bi in, &ea t& stat+s inf$rmati$n 38n$/ ed,e $f t&e need f$r c$ntin+ati$n $f care 3Ri,&t t$ see6 an$t&er $pini$n 38n$/ ed,e $f &+man e7perimentati$n 3C$ntin+in, &ea t&care after disc&ar,e 3(7pected c$nd+ct in t&e $+tpatient settin, fr$m $+tpatient $r inpatient care 3Safety

Fi#a#cial Policy
C$9payments: c$9ins+rance: ded+ctib es and"$r pre9ser-ice dep$sits are d+e at t&e time $f ser-ice. D+e t$ e,a c$nsiderati$ns t&is p$ icy m+st be app ied +nif$rm y. Ins+rance re;+ires pre9a+t&$ri<ati$n. %ayment in f+ is e7pected /it&$+t pr$$f $f a+t&$ri<ati$n. 4&e appr$priate payment is re;+ired at eac& -isit: if t&e patient is a min$r= payment is sti re;+ired re,ard ess $f t&e re ati$ns&ip $f t&e ad+ t t$ t&e min$r. In t&e case $f c&i dren $f di-$rced parents: payment is d+e at t&e time $f ser-ice re,ard ess $f t&e terms $f t&e di-$rce decree. (A)# /i bi t&e ins+rance c$mpany $n be&a f $f t&e patient. )enefits /i be assi,ned. 4&e patient a+t&$ri<es (A)# t$ re ease any necessary inf$rmati$n t$ pr$cess t&e ins+rance c aims. C&ar,es n$t paid by y$+r ins+rance c$mpany /it&in >?@ days /i bec$me t&e patient2s and"$r e,a ,+ardian resp$nsibi ity.

0e#e%al Cli#ical/A(mi#ist%ati'e c*a%+es ,t*e follo)i#+ may apply a#( a%e e2pecte( upo# %e+ist%atio# p%io% to se%'ices $ei#+ (eli'e%e(-& Missed app$intment /it&$+t n$tificati$n by n$$n $f t&e pri$r b+siness day. A Missed app$intments /i res+ t in disc&ar,e fr$m t&e practice. R$+tine paper/$r6 (e.,. re;+ests f$r rec$rds! (7tensi-e paper/$r6 Ret+rned c&ec6 C$+nse $r"4&erapy rate MD rate 9 f$ $/9+p"medicati$n mana,ement MD rate 9 initia inta6e e-a +ati$n /it& $r /it&$+t medicati$n mana,ement MD Dep$siti$n Fee MD Disabi ity (-a +ati$n (c$mp eted paper/$r6! Alte%#ate A%%a#+eme#t: (Staff t$ specify: initia and date! Credit"Debit Card %r$cessin, Fee Credit"Debit Card (.it&$+t card present! %r$cessin, Fee C&ar,e BCC.@@ BC@.@@ B>@@.@@ BA@.@@ B>C@.@@ B>@@.@@ BA@@.@@ BA@@.@@ BA@@.@@ B>.@@ BA.@@ %er App$intment Missed Fi ed Re;+est Fi ed Re;+est Ret+rn Sessi$n Sessi$n Sessi$n #$+r (-a +ati$n Card %r$cessin, Card %r$cessin,

1353 Jennings Mill Rd Suite C Box 7, Bogart GA 30622 706-357-5 67 !""i#e $$$ 706-357-5 6% &ax

APPOINTMENT POLICY C$ns+ tati$n /it& staff is by app$intment $n y. Ca +s at D@E9ACD9CFED t$ sc&ed+ e an app$intment. (ac& time t&at y$+ ca t&e c inic: $+r staff may c$nfirm t&at $+r rec$rds &a-e y$+r c$rrect daytime and e-enin, te ep&$ne n+mbers as /e as y$+r c$rrect mai in, address. 4&is /i a $/ $+r c inic staff t$ c$ntact y$+ /&en re;+ired. At eac& -isit: p ease brin, y$+r ins+rance card /it& y$+ and be prepared t$ pay t&e c$9payment $r ded+ctib e. If y$+ are c$nsidered a f+ pay patient: p ease be prepared t$ pay t&e a,reed +p$n am$+nt. %ayment is re;+ested at t&e time $f y$+r app$intment. Ne/ %atients: % ease arri-e t&irty (A@! min+tes bef$re y$+r sc&ed+ ed app$intment t$ c$mp ete t&e re,istrati$n f$rms. (7istin, %atients: M+st c$mp ete ne/ re,istrati$n f$rms ann+a y. EMAIL POLICY Gnf$rt+nate y: /e d$ n$t pr$-ide t&is ser-ice d+e t$ en$rm$+s -$ +me $f spam emai . At t&is time /e d$ N'4 accept emai s f$r app$intment re;+ests"cance ati$ns $r prescripti$n refi re;+ests. CALL THE OFFICE for urgent medical situations PLEASE DO NOT USE E AIL TELEP ONE CALL POLICY If y$+ are &a-in, an emer,ency $f a medica nat+re: p ease ca H>> immediate y. R$+tine ca s and messa,es are ,i-en t$ t&e appr$priate pers$n as s$$n as p$ssib e: and e-ery attempt is made t$ ret+rn te ep&$ne ca s d+rin, re,+ ar /$r6in, &$+rs. 4&ere are times: &$/e-er: /&en /e cann$t ans/er a ca s /it&in t&e same day t&ey are recei-ed. % ease ea-e a messa,e and s$me$ne fr$m $+r staff /i ca y$+ at t&e ear iest p$ssib e time. TEST RES!LT POLICY It ta6es a minim+m $f A days t$ recei-e test res+ ts. I$+ /i be n$tified $f any a$#o%mal test res+ ts. If y$+ &a-e n$t &eard fr$m t&e c inica staff /it&in t&is time: p ease ca t&e c inic. AN1ICAP ACCESSI"ILITY .e /ant t$ ens+re t&at y$+r -isit t$ $+r c inic is as c$n-enient and c$mf$rtab e as p$ssib e. 4&ere are se-era &andicap accessib e par6in, spaces in fr$nt $f t&e entrance t$ t&e b+i din,. 4&e inside $f t&e b+i din, is a sm$6e9free en-ir$nment. 4&e $ffice restr$$m is ADA c$mp iant. PRESCRIPTION REFILL POLICY 4&e %syc&iatrist /i ma6e t&e fina determinati$n f$r a prescripti$n refi re;+est. >. N$ prescripti$ns are refi ed f$r m$re t&an E@ days /it&$+t an $ffice -isit and is determined by t&e type $f psyc&$tr$pic medicati$n prescribed. J. N$ refi re;+est -ia te ep&$ne /i be accepted. Fee free t$ &a-e y$+r p&armacy fa7 t&e refi re;+ests f$r re-ie/ t$ D@E9ACD9 CFE?. A. .e /i ma6e e-ery attempt t$ ans/er a R7 re;+ests /it&in JF9F? &$+rs M9F. F. Gnder n$ circ+mstances are certain psyc&$tr$pic medicati$ns prescribed /it&$+t an $ffice -isit.

"y si+#i#+3 you a%e stati#+ t*at you a%e i# a+%eeme#t )it* t*e a$o'e policies a#( p%oce(u%es liste( fo% Easte%# Atla#ta "e*a'io%al ealt*3 LLC.
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Patient/Legal Guardian/Parent Signature


.e t&an6 y$+ f$r se ectin, (astern At anta )e&a-i$ra #ea t&: LLC t$ pr$-ide y$+r be&a-i$ra &ea t& ser-ices. (-ery eff$rt /i be made t$ pr$-ide y$+ /it& ;+a ity care: pr$fessi$na s+pp$rt: respect and c$nsiderati$n. % ease inf$rm $+r staff immediate y s&$+ d t&ere be ;+esti$ns $r c$ncerns


1353 Jennings Mill Rd Suite C Box 7, Bogart GA 30622 706-357-5 67 !""i#e $$$ 706-357-5 6% &ax

I: _________________________________ a+t&$ri<e (astern At anta )e&a-i$ra #ea t& ((A)#! t$ bi my ins+rance c$mpany f$r c&ar,es inc+rred d+rin, t&e c$+rse $f my treatment and t$ pr$-ide any inf$rmati$n necessary t$ pr$cess my c aims and t$ c$ ect payment. I a+t&$ri<e my ins+rance c$mpany t$ &$n$r a p&$t$c$py $f t&is a+t&$ri<ati$n and t$ assi,n my ins+rance benefits f$r t&ese c&ar,es t$ (A)#. Si,ned:_____________________________________ Date:___________________________________ .itness:____________________________________ Date:___________________________________

I: _________________________________ : a,ree and c$nsent t$ participate in be&a-i$ra &ea t& care ser-ices $ffered and pr$-ided by (astern At anta )e&a-i$ra #ea t& ((A)#! and be&a-i$ra &ea t& pr$-iders. I accept t&e c$nditi$ns f$r recei-in, ser-ices fr$m (A)#. I(/e! &a-e re-ie/ed a c$py $f (A)#0s N$tice $f %ri-acy %ractice and p$ icy and pr$ced+res. I +nderstand t&at I am c$nsentin, and a,reein, $n y t$ t&$se ser-ices t&at t&e ab$-e named pr$-ider is ;+a ified t$ pr$-ide /it&in (>! t&e sc$pe $f t&e pr$-ider2s icense: certificati$n: and tranin,= $r (J! t&e sc$pe $f icense: certificati$n: and tranin, $f t&e be&a-i$ra &ea t& care pr$-iders direct y s+per-isin, t&e ser-ices recei-ed by t&e patient. If t&e patient is +nder t&e a,e $f ei,&teen $r +nab e t$ c$nsent t$ treatment: I attest t&at I &a-e e,a c+st$dy $f t&is indi-id+a and am a+t&$ri<ed t$ initiate and c$nsent f$r treatment and"$r e,a y a+t&$ri<e t$ initiate and c$nsent t$ treatment $n be&a f $f t&is indi-id+a .

Si,ned:_____________________________________ Date:___________________________________ Re ati$ns&ip t$ %atient (if app icab e!:____________________________________________________ .itness:____________________________________ Date: ___________________________________



1353 Jennings Mill Rd Suite C Box 7, Bogart GA 30622 706-357-5 67 !""i#e $$$ 706-357-5 6% &ax

Name:____________________________________________________________________________ Me#tal ealt* ospitali4atio#s& Iear Name $f #$spita C$nditi$n

Su%+e%ies& Iear 4ype

3Ot*e% se%ious me(ical co#(itio#s&55555555555555555555555555555555555555555555555555555555555555 ___________________________________________________________________________________________ Cu%%e#t me(icatio#s& Name D$sa,e Sc&ed+ e

isto%y of To$acco use6 Yes No

isto%y of 1%u+ use6 Yes No

isto%y of Alco*ol use6 Yes No

A%e you alle%+ic to a#y me(ici#es6 YES NO If yes3 )*ic*6555555555555555555555555555555555555555555 a'e you e'e% *a( a sei4u%e6 YES NO If so3 )*e# )as t*e last time65555555555555555555555555555555555 a'e you *a( a loss of co#scious#ess6 YES NO If so3 )*e# )as t*e last time655555555555555555555555555 Name of a#y me#tal *ealt* (octo%s you *a'e see# i# t*e last 7 yea%s& >.__________________________________________________________________________________________ J.__________________________________________________________________________________________ A.__________________________________________________________________________________________ F.__________________________________________________________________________________________

IPPA 0eo%+ia Notice Fo%m

1353 Jennings Mill Rd Suite C Box 7, Bogart GA 30622 706-357-5 67 !""i#e $$$ 706-357-5 6% &ax

N$tice $f %$ icies and %ractices t$ %r$tect t&e %ri-acy $f I$+r #ea t& Inf$rmati$n in Acc$rdance /it& t&e #ea t& Ins+rance %$rtabi ity and Acc$+ntabi ity Act (#I%AA! and Ge$r,ia State La/s. 4#IS N'4IC( D(SCRI)(S #'. %SIC#'L'GICAL AND M(DICAL INF'RMA4I'N A)'G4 I'G MAI )( GS(D AND DISCL'S(D AND #'. I'G CAN G(4 ACC(SS 4' 4#IS INF'RMA4I'N. %L(AS( R(5I(. I4 CAR(FGLLI. !ses a#( 1isclosu%es fo% T%eatme#t3 Payme#t3 a#( ealt* Ca%e Ope%atio#s (astern At anta )e&a-i$ra #ea t&: LLC and its a,ents may +se $r disc $se y$+r pr$tected &ea t& inf$rmati$n (%#I!: f$r treatment: payment: and &ea t& care $perati$ns p+rp$ses /it& y$+r c$nsent. 4$ &e p c arify t&ese terms: &ere are s$me definiti$ns: K%#IL refers t$ inf$rmati$n in y$+r &ea t& rec$rd t&at c$+ d identify y$+. K4reatment: %ayment and #ea t& Care 'perati$nsL $ 4reatment is /&en y$+r &ea t& care pr$-ider pr$-ides: c$$rdinates $r mana,es y$+r &ea t& care and $t&er ser-ices re ated t$ y$+r &ea t& care. An e7amp e $f treatment /$+ d be /&en y$+r &ea t& care pr$-ider c$ns+ ts /it& an$t&er pr$-ider: s+c& as a fami y p&ysician $r an$t&er psyc&$ $,ist. $ %ayment is /&en y$+r &ea t& care pr$-ider $btains reimb+rsement f$r y$+r &ea t&care. (7amp es $f payment are /&en y$+r &ea t& care pr$-ider disc $ses y$+r %#I t$ y$+r &ea t& ins+rer t$ $btain reimb+rsement f$r y$+r &ea t& care pr$-ider $r t$ determine e i,ibi ity f$r c$-era,e. $ #ea t& Care 'perati$ns are acti-ities t&at re ate t$ t&e perf$rmance and $perati$n $f t&e practice $f (astern At anta )e&a-i$ra #ea t&: LLC KGseL app ies $n y t$ acti-ities /it&in t&e &ea t& care pr$-ider practice s+c& as s&arin,: emp $yin,: app yin,: +ti i<in,: e7aminin,: and ana y<in, inf$rmati$n t&at identifies y$+. KDisc $s+reL app ies t$ acti-ities $+tside $f t&e &ea t& care pr$-ider2s practice s+c& as re easin,: transferrin,: $r pr$-idin, access t$ inf$rmati$n ab$+t y$+ t$ $t&er parties. !ses a#( 1isclosu%es Re8ui%i#+ Aut*o%i4atio# (astern At anta )e&a-i$ra #ea t&: LLC may +se $r disc $se %#I f$r p+rp$ses $+tside $f treatment: payment: $r &ea t& care $perati$n /&en y$+r appr$priate a+t&$ri<ati$n is $btained. An KA+t&$ri<ati$nL is /ritten permissi$n ab$-e and bey$nd t&e ,enera c$nsent t&at permits $n y specific disc $s+res. In t&$se instances /&en y$+r &ea t& care pr$-ider is as6ed f$r inf$rmati$n f$r p+rp$ses $+tside $f treatment: payment $r &ea t& care $perati$ns: y$+r &ea t& care pr$-ider /i $btain an a+t&$ri<ati$n fr$m y$+ bef$re re easin, t&is inf$rmati$n. (astern At anta )e&a-i$ra #ea t& LLC /i a s$ need t$ $btain an a+t&$ri<ati$n bef$re re easin, y$+r %syc&$t&erapy N$tes. K%syc&$t&erapy N$tesL are n$tes y$+r &ea t& care pr$-ider &as made ab$+t c$n-ersati$ns /it& y$+ d+rin, pri-ate: ,r$+p: M$int: $r fami y c$+nse in, sessi$ns. 4&ese are 6ept separate fr$m t&e rest $f y$+r medica rec$rd and are ,i-en a ,reater de,ree $f pr$tecti$n t&an %#I. I$+ may re-$6e a s+c& a+t&$ri<ati$ns at any time: pr$-ided eac& re-$cati$n is in /ritin,. I$+ may n$t re-$6e an a+t&$ri<ati$n t$ t&e e7tent t&at (>! y$+r &ea t& care pr$-ider &as re ied $n t&at a+t&$ri<ati$n= $r (J! if t&e a+t&$ri<ati$n /as $btained as a c$nditi$n $f $btainin, ins+rance c$-era,e: a/ pr$-ides t&at t&e ins+rer t&e ri,&t t$ c$ntest t&e c aim +nder t&e p$ icy. !ses a#( 1isclosu%es )it* Neit*e% Co#se#t #o% Aut*o%i4atio# I$+r &ea t& care pr$-ider may +se $r disc $se %#I /it&$+t y$+r c$nsent $r a+t&$ri<ati$n in t&e f$ $/in, circ+mstances: S+spected c&i d ab+se $r dependent (-+ nerab e! ad+ t $r e der ab+se. (4&e t&erapist is re;+ired by a/ t$ rep$rt t&is t$ t&e appr$priate a+t&$rities immediate y! If a c ient is t&reatenin, seri$+s b$di y &arm t$ an$t&er pers$n $r pers$ns. (4&e t&erapist m+st n$tify t&e p$ ice and inf$rm t&e intended -ictim! If a c ient intends t$ &arm &imse f $r &erse f $r ac6s t&e capacity t$ care f$r &im $r &erse f. (4&e t&erapist m+st ma6e e-ery eff$rt t$ en ist t&e c ient2s c$$perati$n in ens+rin, t&eir safety. If t&e c ient d$es n$t c$$perate: f+rt&er meas+res m+st be ta6en /it&$+t t&e c ient2s permissi$n in $rder t$ 6eep t&e c ient safe: i.e. ca in, H>>.! %renata (7p$s+re t$ C$ntr$ ed S+bstances. (Menta #ea t& care pr$fessi$na s are re;+ired t$ rep$rt admitted prenata e7p$s+re t$ c$ntr$ ed s+bstances t&at are p$tentia y &armf+ .! N+dicia and Administrati-e %r$ceedin,s9 /&ere t&e icensee is a defendant in a ci-i : crimina : $r discip inary acti$n arisin, fr$m t&e t&erapy: in /&ic& case c ient c$nfidences may be disc $sed in t&e c$+rse $f t&at acti$n. .&en t&ere is a -a id c$+rt $rder f$r t&e disc $s+re $f c ient fi es. (4&is is -ery rare and /i be re-ie/ed by $+r att$rney bef$re &andin, anyt&in, $-er t$ t&e c$+rts.! 1353 Jennings Mill Rd Suite C Box 7, Bogart GA 30622 706-357-5 67 !""i#e $$$ 706-357-5 6% &ax

4$ c$mp y /it& a/s re atin, t$ /$r6ers0 c$mpensati$n and simi ar a/s. #ea t& '-ersi,&t Acti-ities: If pr$-ider is s+bMect $f an in;+iry by t&e Ge$r,ia )$ard $f %syc&$ $,ica (7aminers: pr$-ider may be re;+ired t$ disc $se pr$tected &ea t& care inf$rmati$n re,ardin, y$+ in pr$ceedin,s bef$re t&e )$ard. 't&er +ses and disc $s+res $f %#I n$t described in t&is n$tice /i be made $n y /it& y$+r a+t&$ri<ati$n. Patie#t/s Ri+*ts Ri,&t t$ Re;+est Restricti$ns9 I$+ &a-e t&e ri,&t t$ re;+est restricti$ns f$r certain +ses and disc $s+res $f pr$tected &ea t& inf$rmati$n b+t /e are n$t re;+ired t$ a,ree t$ a restricti$n at y$+r re;+est. #$/e-er: /e /i c$mp y /it& a restricti$n re;+est if (e7cept as $t&er/ise re;+ired by a/!: t&e disc $s+re is t$ a &ea t& p an f$r p+rp$ses $f carryin, $+t payment $r &ea t& care $perati$ns and (J! t&e %#I pertains s$ e y t$ a &ea t& care item $r ser-ice f$r /&ic& y$+ $r an$t&er pers$n &as paid +s: in f+ : $+t9$f9p$c6et. Ri,&t t$ Recei-e C$nfidentia C$mm+nicati$ns by A ternati-e Means and at A ternati-e L$cati$ns9 I$+ &a-e t&e ri,&t t$ re;+est and recei-e c$nfidentia c$mm+nicati$ns $f %#I by a ternati-e means and a ternati-e $cati$ns. (i.e.: y$+ may n$t /ant y$+r fami y member $r r$$mmate t$ 6n$/ t&at y$+ are seein, a t&erapist. 'n y$+r re;+est: /e /i ea-e messa,es at an a ternati-e $cati$n $r bi t$ an$t&er address.! Ri,&t t$ Inspect and C$py9 I$+ &a-e t&e ri,&t t$ inspect $r $btain a c$py ($r b$t&! $f %#I in y$+r &ea t& care pr$-ider2s menta &ea t& and bi in, rec$rds +sed t$ ma6e decisi$ns ab$+t y$+ f$r as $n, as t&e %#I is maintained in t&e rec$rd. I$+r &ea t& care pr$-ider may deny y$+r access t$ %#I +nder certain circ+mstances: b+t in s$me cases y$+ may &a-e t&is decisi$n re-ie/ed. 'n y$+r re;+est: /e /i disc+ss /it& y$+ t&e detai s $f t&e re;+est and t&e denia pr$cess. Ri,&t t$ an Acc$+ntin,9 I$+ ,enera y &a-e t&e ri,&t t$ recei-e an acc$+ntin, $f disc $s+res $f %#I. 'n y$+r re;+est: /e /i disc+ss /it& y$+ t&e detai s $f t&e acc$+ntin, pr$cess. Ri,&t t$ be N$tified $f a )reac& 9 I$+ &a-e t&e ri,&t t$ be n$tified in t&e e-ent t&at /e disc$-er a breac& $f y$+r +nsec+red pr$tected &ea t& inf$rmati$n. N$tice $f any s+c& breac& /i be made in acc$rdance /it& federa re;+irements. Ri,&t t$ a %aper C$py9 I$+ &a-e t&e ri,&t t$ $btain a paper c$py $f t&e n$tice fr$m t&is $ffice +p$n re;+est: e-en if y$+ &a-e a,reed t$ recei-e t&e n$tice e ectr$nica y. Complai#ts If y$+ &a-e ;+esti$ns ab$+t t&is n$tice: disa,ree /it& a decisi$n t&is $ffice ma6es ab$+t access t$ y$+r rec$rds: $r &a-e $t&er c$ncerns ab$+t y$+r pri-acy ri,&ts: y$+ may c$ntact y$+r pr$-ider at t&is $ffice at D@E9ACD9CFED.If y$+ be ie-e t&at y$+r pri-acy ri,&ts &a-e been -i$ ated and /is& t$ fi e a c$mp aint /it& t&is $ffice: y$+ may send y$+r /ritten c$mp aint t$ (astern At anta )e&a-i$ra #ea t& >ACA Nennin,s Mi Rd. S+ite C )$,art: GA A@EJJ.I$+ may a s$ send a /ritten c$mp aint t$ t&e Secretary $f t&e G.S. Department $f #ea t& and #+man Ser-ices and /e can pr$-ide y$+ /it& t&e appr$priate address +p$n re;+est. Effecti'e 1ate3 Rest%ictio#s3 C*a#+es to P%i'acy Policy 4&is n$tice /ent int$ effect $n September JA: J@>A. 4&is $ffice reser-es t&e ri,&t t$ c&an,e t&e terms $f t&is n$tice: ma6e restricti$ns $r imitati$ns: and ma6e t&e ne/ n$tice pr$-isi$ns effecti-e f$r a %#I if t&is $cc+rs /e /i n$tify $+r c ients. I !a"e read and recei"ed a co#$ of t!e notice of %EO&%IA HIPPA NOTICE ' Notice of Policies and Practices to Protect t!e Pri"ac$ of (our Healt! Information in Accordance )it! t!e Healt! Insurance Porta*ilit$ and Accounta*ilit$ Act +HIPAA, and %eorgia State La)s-

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1353 Jennings Mill Rd Suite C Box 7, Bogart GA 30622 706-357-5 67 !""i#e $$$ 706-357-5 6% &ax