agree to participate in treatment with and through the GMCS Psychiatric Rehabilitation Program. I understand that this treatment will be for my mental health and physical welfare. I will participate in developing my treatment plan with my counselor and have all recommendations explained to me in full.

I understand that I have the right to ethical and fair treatment given without regard to my race, religion, ethnic origin, sexual orientation, or color. I understand that I have the right to appeal against any decision made in my treatment by first discussing it with my primary treating professional. I understand that if I am not satisfied with the determination of this appeal, I may appeal to the Medical Director and the Executive Director. I understand that I may refuse treatment with 48 hours notice. I understand that if I choose to refuse treatment or to rescind this agreement for treatment with GMCS against medical advice, I will hold GMCS blameless and harmless for any pain or suffering I may incur because of that refusal or cessation of treatment. I have been given a copy of Client Rights, Grievance Process, and Maryland Notice Form for my review:

I understand that I may be discharged from GMCS under the following conditions:

1. Successful completion of treatment goals
2. Failure to keep regular appointments or failure to attend sessions for a 90-day period.
3. Decision regarding different choice of treatment
4. Refusal to follow agreed-upon goals.
5. Persistent AWOL behavior
6. Disrespectful behavior
7. Violent and/or criminal activities.

I give GMCS and their representative coassignee permission to share any information necessary with any insurance company to obtain payment for medical services to me.

request that Grace and Mercy Community Services handle my confidential health information in the following way:

All reasonable requests to receive communication of your health information by alternative means will be granted. Please describe the alternative means (e.g., US mail, telephone call, etc.) by which you prefer to receive your health information.

All reasonable requests to receive communication of your health information at alternative locations will be granted. Please complete the following section only if you want communications regarding your health care information sent to an alternate address (other than your residence).

I verify that I am aware of the effects of the medications prescribed by the psychiatrist for my/my child's condition. I have been provided with written descriptive information regarding these medications, including benefits, risks, and side effects. I have been afforded the opportunity to ask questions regarding these benefits, risks and side effects. Having been duly informed, I consent to treatment with this medication.

I/We hereby authorize Grace and Mercy Community Services to send my personal Health Information to or receive from other mental Health establishments that are concerned with my care and wellbeing.

I authorize this clinic to speak by telephone with you about the reasons for referral, and relevant history, or diagnoses, and to share other information to assist with the client's treatment and/or evaluation.

This authorization to release information is being made to aid in planning effective evaluation and treatment for this client. I understand that no services will be denied solely because I refuse to consent to this release of information, and that I am not obligated to release them. I do release them because I believe they are necessary to assist in the development of the best possible treatment plan for the client.

In consideration of this consent, I hereby release the above source of records from all liability arising there from. I understand that I may void this authorization, except for action already taken, at any time by means of a written letter revoking the authorization and transfer of information, but that this revocation is not retroactive. Unless expressly revoked earlier, this consent expires upon completion of the current treatment and/or one year from the current date.

As a client of GMCS, you have the right to:

1. Receive appropriate humane treatment, which minimizes restriction of your personal liberty only to the extent necessary for your treatment needs, and applicable legal requirements.

2. Be protected from harm and to be free from mental, physical, and sexual abuse at the facility. All allegations of client abuse by staff members must be reported to the local law enforcement agency or to the program director that must report them to the local law enforcement agency.

3. An individualized treatment plans.

4. Participate, in a manner appropriate to your condition, in the development and periodic review of your treatment plan.

5. Receive treatment as stated in your individualized treatment plan

6. Be told in appropriate terms and language of:

1) The contents and objectives of treatment or rehabilitation.
2) The nature and significant possible negative effects of treatment or rehabilitation.
3) The name, title and role of staff members who are directly involved in your treatment, and when appropriate, the names of other treatments, services, or providers of mental health services.

7. Access your treatment records and the right, with written permission, for your attorney to have access to your records. In the event your treatment provider believes that it would be harmful to you to read your record, you have the right to a written summary of those sections of the record your treatment provider believes might be harmful.

8. Refuse medication.

9. Refuse to participate in physically intrusive research.

10. Prior to admission, to an explanation in terms and language that you can understand of admission and discharge policies.

BILL OF CLIENT'S RIGHTS - P2

11. Prior to admission, to an explanation of your rights in terms and language that you can understand, and to have a list of your rights posted in a prominent place in the facility.

12. Prior to admission, to an explanation in terms and language that you can understand, of the charges and fees that you will be required to pay.

13. An aftercare plan.

14. File a grievance if you are not satisfied with the treatment you receive.

Notice of Policies and Practices to Protect the Privacy of Your Health Information
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL, PSYCHIATRIC REHABILITATION AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION, PLEASE REVIEW IT CAREFULLY.

I. Uses and Disclosures for Treatment, Payment, and Health Care Operations
Grace & Mercy Community Service may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your written authorization. To help clarify these terms, here are some definitions:
• "PHI" refers to information in your health record that could identify you.
• "Treatment, Payment, and Health Care Operations"
- Treatment is when we provide, coordinate, or manage your health care and other services related to your health care. An example of treatment would be when we consult with another health care provider, such as your family physician or another mental health provider.
- Payment is when we obtain reimbursement for your health care. Examples of payment are when we disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
- Health Care Operations are activities that relate to the performance and operation of the Young Adult Institute. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.
• "Use" applies only to activities within the clinic such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
• "Disclosure" applies to activities outside of the clinic, such as releasing, transferring, or providing access to information about you to other parties.
• "Authorization" is your written permission to disclose confidental mental health information. All authorizations to disclose must be on a specific legally required form.

II. Other Uses and Disclosures Requiring Authorization
GMCS may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained. In those instances when we are asked for information for purposes outside of treatment, payment, or health care operations, we will obtain an authorization from you before releasing this information. GMCS will also need to obtain an authorization before releasing your Psychotherapy Notes. "Psychotherapy Notes" are notes that have been made about a conversation during a private, group, joint, or family counseling session, which have kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI.
You may revoke all such authorizations (of PHI or Psychotherapy Notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) we have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.

III. Uses and Disclosures without Authorization
GMCS may use or disclose PHI without your consent or authorization in the following circumstances:
• Child Abuse - If there is reason to believe that a child has been subjected to abuse or neglect, we mușt report this belief to the appropriate authorities.
• Adult and Domestic Abuse - GMCS may disclose protected health information regarding you if there is reasonable belief that you are a victim of abuse, neglect, self-neglect, or exploitation.
• Health Oversight Activities -If GMCS receives a subpoena from the Maryland Board of Examiners of Physicians, Psychologists, Social Workers, Professional Counselors, or any other Mental Health Board because they are investigating the Clinic or any staff member, we must disclose any PHI requested by the Board.
• Judicial and Administrative Proceedings - If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment or the records thereof, such information is privileged under state law, and GMCS will not release information without your written authorization or a court order. The privilege does not apply when you are being evaluated or a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.
Serious Threat to Health or Safety - If you communicate a specific threat of imminent harm against another individual or if any GMCS staff member believes that there is clear, imminent risk of physical or mental injury being inflicted against another individual, we may make disclosures that we believe are necessary to protect that individual from harm. If GMCS staff believes that you present an imminent, serious risk of physical or mental injury or death to yourself, we may make disclosures we consider necessary to protect you from harm.

IV. Patient's Rights and Clinical Staff's Duties
IV. Patient's Rights
• Right to Request Restrictions - You have the right to request restrictions on certain uses and disclosures of protected health information. However, GMCS is not required to agree to a restriction you request.
• Right to Receive Confidential Communications by Alternative Means and at Alternative Locations - You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are being seen at the Clinic. At your request, we will send your bills or other information to another address.)
• Right to Inspect and Copy - You have the right to inspect or obtain a copy (or both) of PHI in the mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. GMCS may deny your access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. You have the right to inspect or obtain a copy (or both) of Psychotherapy Notes unless we believe the disclosure of the record will be injurious to your health. On your request, your mental health provider will discuss with you the details of the request and denial process for both PHI and Psychotherapy Notes.
• Right to Amend - You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. GMCS may deny your request. At your request, a staff member will discuss with you the details of the amendment process.
• Right to an Accounting - You generally have the right to receive an accounting of disclosures of PHI. At your request, a staff member will discuss the details of the accounting process with you.
• Right to a Paper Copy - You have the right to obtain a paper copy of the notice upon request, even if you have agreed to receive the notice electronically.

GMCS Duties
• GMCS is required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI.
• We reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect.
• If we revise our policies and procedures, we will inform you verbally and/or in writing during the session following the revision.

V. Questions and Complaints
If you have questions about this notice, disagree with a decision made about access to your records, or have other concerns about your privacy rights, you may contact the Clinical Director at the above number.

If you believe that your privacy rights have been violated and wish to file a complaint with the clinic, you may send your written complaint to the above address.

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The person listed above can provide you with the appropriate address upon request.

You have specific rights under the Privacy Rule. GMCS will not retaliate against you for exercising your right to file a complaint.

VI. Effective Date, Restrictions, and Changes to Privacy Policy
This notice will go into effect on May 1, 2020

GMCS reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that we maintain. We will provide you with a revised notice either verbally and/or in writing by, at the latest, during the session following the time of the revision.

I have received a copy of this notice.

1. In the event you have a grievance you may personally, through or in combination with other persons, present grievances and recommend changes in policies and services on behalf of yourself or others without fear of reprisal, interference, coercion, ot discrimination.

2. A grievance may be initiated verbally but must be confirmed in writing to the program director.

3. The director will forward the grievance for review to the supervisor of a service area, a senior clinician, or an ad hoc committee.

4. The director will review the report of the supervisor, clinician, or ad hoc committee and respond in writing to the grievance.

5. All of the above steps will be completed within 14 working days.

6. If appropriate, the written response will include an assessment of any factors contributing to the grievance, and proposed remedies, if any, to prevent a reoccurrence of problems.

7. If you are not satisfied with the outcome of this internal process, you may forward your grievance to the Maryland BHA.

I have been informed of the policies and procedures for submitting a grievance. I understand the policies and procedures as explained to me. If there is any portion of the procedures that require further explanation, I understand that I am free to request an explanation and assistance now or in the future.

authorize Grace & Mercy Community Service Psychiatric Rehabilitation Program to provide rehabilitation services.

The purpose of this consent form is to inform you about the services provided by Grace and Mercy Community Services Inc. (GMCS) and to obtain your consent for receiving services in accordance with the standards set by the Commission on Accreditation of Rehabilitation Facilities (CARF) and the Code of Maryland Regulations (COMAR).

Acknowledgement of Services

Grace and Mercy Community Services Inc. (GMCS) provides mental health and related services through an Outpatient Mental Health Clinic (OMHC). These services include, but are not limited to:
• Psychiatric assessments and evaluations
• Individual, group, and family therapy
• Case management services
• Medication management
• Crisis intervention and stabilization

All services are provided in accordance with the standards set forth by CARF (Commission on Accreditation of Rehabilitation Facilities) and COMAR (Code of Maryland Regulations) to ensure high-quality care, confidentiality, and compliance with state and federal regulations.

Confidentiality and Privacy

Your personal and health information will be kept confidential and protected under federal and state law. GMCS adheres to all confidentiality regulations outlined under the Health Insurance Portability and Accountability Act (HIPAA) and Maryland's Health General Article, including the protection of mental health records.

• Your personal health information will only be shared with your written consent, except as required by law or for medical emergencies.
• You have the right to request a copy of your records and to request corrections to any errors in your records.

Rights and Responsibilities

As a consumer of GMCS services, you have the following rights:

Right to Informed Consent: You have the right to be fully informed about the services provided and their potential benefits and risks before consenting to any treatment or service.

Right to Confidentiality: Your personal and treatment information will be kept confidential unless you provide written consent for disclosure or unless disclosure is required by law.

Right to Respect and Dignity: You will be treated with respect, dignity, and courtesy at all times during your care.

Right to a Safe Environment: You have the right to receive care in an environment that is free from abuse, harassment, or discrimination.

Right to Refuse or Discontinue Treatment: You may refuse services or discontinue treatment at any time, understanding the potential consequences of doing so.

Right to Appeal: If you feel that your rights have been violated or that you are dissatisfied with services, you have the right to file a complaint or appeal as outlined in GMCS's grievance procedure.

Consumer Consent

I, the undersigned, consent to receive services from Grace and Mercy Community Services Inc. (GMCS) as outlined in this form. I have had the opportunity to ask questions and receive clear explanations about the nature of the services, potential risks and benefits, confidentiality protections, and my rights as a client.

I understand that I have the right to refuse services or withdraw consent at any time without penalty or loss of benefits.

I also acknowledge that I have been provided with a copy of the GMCS Client Rights and Responsibilities, as well as the privacy practices related to the handling of my health information.

By signing this consent form, I am voluntarily agreeing to participate in the services offered by GMCS and confirm that I understand my rights and responsibilities.