EMPLOYEE ASSISTANCE PROGRAM Provided by NEW DIRECTIONS EAP

EMPLOYEE ASSISTANCE PROGRAM Provided by NEW DIRECTIONS EAP is designed to provide short-term counseling services, work-life support, legal and financial guidance to help you and your family handle concerns constructively before they become major issues. Areas of assistance include: • Confidential, free counseling • Legal assistance and support • Financial Information and Resources • Personalized work-life solutions for childcare, eldercare, moving and more! 1)

TWO WAYS TO OBTAIN SERVICES 1) The Employee request assistance The Employee self-request is free for up to six visits The employer will not know you reached out The company code is ARBenefits Contact New Directions at 877 -300 -9103 or ndbh. com

2) Supervisor Requires Employee Assistance The formal referral is from the supervisor Contact HR Benefits at 501 -212 -5115 Benefits Analyst, employee and supervisor place call to New Directions Employee will complete and sign an Authorization for Release of Protected Health Information (PHI) form Release of information will be to: Terressa Galbraith, Benefits Analyst Bldg 4201 Box 28 CJTR, North Little Rock, AR 72199 New Directions will notify HR Benefits each time employee has had a meeting New Directions will advise at end of six sessions if there is a need for more counseling

Authorization for Release of Protected Health Information (PHI) NEW DIRECl. T )NS' Sections 1 through 9 must be completed for this authorization to be valid. INCOMPLETE FORMS will not be processed and will be returned to the requestor for additional information. A copy of this authorization form will be available to you, but you should retain a copy for your records. 1. MEMBER INFORMATION TO BE RELEASED Print Name Of Member Health Plan I. D. Number Member Date of Birth Member Address Member Secondary Phone Number Member Primary Phone Number 2. NEW DIRECTIONS WILL RELEASE MEMBER INFORMATION TO Organization or Person Address City, State, Zip Primary Phone Number Secondary Phone Number Email Address Fax Number 3. PREFERRED DELIVERY METHOD D Mail Information D Email Information (If file size permits) □ Fax Information (If file size permits) Note: If information is shared with aperson ororaanization that is not leaally reguired to obey privacy laws, the information may be shared with others and may no lon 2 er be protected. 4. PURPOSE OF RELEASE D Legal □ Insurance D Other D Healthcare provider D Copies for personal use

5. INFORMATION TO BE RELEASED (Please check only one box) All infonnation about eligibility, enrollment, plan benefits, claims, con·espondence to or from New Directions and prior authorization or dete 1 minations for services provided by any physician or hospital. (INCLUDING alcohol and substance use or abuse infonnation). □ All infonnation about eligibility, enrollment, plan benefits, claims, correspondence to or from New Directions and prior authorization or detenninations for services provided by any physician or hospital. (EXCLUDING alcohol and substance use or abuse infom 1 ation). □ Only specific infonnation: D 6. RELEASE INFORMATION PERTAINING TO THIS TIME PERIOD (Please check only one box) □ Any and all dates, including future dates until expiration of authorization □ From I MM/DD/YYYY 7. EXPIRATION OF AUTHORIZATION Valid for one {1) year unless othetwise specified or revoked. 8. PATIENT AUTHORIZATION I understand that: • Tl e information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected by federal privacy regulations. • New Directions does not condition payment, enrollment, or eligibility for benefits on whether I sign thisauthorization. • I may revoke this authorization at any time by notifying New Directions. Revocation of this authorization will not affect any action taken in reliance of this authorization before the revocation was received. If signing authorization as Power of Attorney, Power of Attorney for Health Care, or Guardian/Conservator, a copy of the legal document MUST ACCOMPANYthis form. 9. SIGNATURE Date (MM/DDNYYY) (Member, Guardian, or Authorized Representative) Relationship of Authorized Representative to Member Minor Signature {Signature of Minor. Where Required) Date {MM/DDNYYY) Substance use disorder records are protected under federal law, including the federal regulations governing the confidentiality of substance use disorder patient records, 42 C. F. R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), 45 C. F. R. Parts 160 and 164, and cannot be disclosed without written consent unless otherwise provided for by the regulations. 2

INSTRUCTIONS FOR COMPLETING THE AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION (PHI) Fill out the form completely. The authorization is not valid unless it is filled out completely. Section 1. Member Information to Be Released. Include the following information about the member whose protected infonnation is being disclosed: 1. First and last name. 2. Date of birth. 3. Health Plan ID number as it appears on the member's insurance card (if applicable). 4. Full street address, including city, state and zip code. 5. Telephone number, including area code. Section 2. New Directions Will Release Member Information To. Include the following infonnation about the organization or person to whom the PHI will be disclosed: 1. 2. 3. 4. 5. Name of organization or person. Full street address, including city, state and zip code of person or organization listed. Primary phone number of organization or person listed. Email address (if applicable). Fax number (if applicable). Section 3. Preferred Delivery Method. All records will be emailed unless an email or fax number is provided AND the file size permits. Check the appropriate box to have infonnation faxed or e-mailed. Files must. meet size requirements and will be encrypted, Section 4. Purpose of Release. Check any and all boxes that describe the purpose of the disclosure. If "other" is chosen, list the purpose in the space provided. Section 5. Information to Be Released. Tell us what infonnation you are authorizing New Directions to release by checking the appropriate box. If you want only specific information disclosed, fill in the blank provided. Section 6. Release Information Pertaining to This Time Period. Check the box that covers the date range of infonnation you would like to release. Section 7. Expiration of Authorization. The authorization is valid for one year unless otherwise specified or revoked. If you wish to revoke your authorization, contact New Directions. Section 8. Patient Authorization. Please read this section all the way through. Section 9. Signature. Sign and date in the space provided to complete this authorization. If a personal representative (someone with legal authority to act on the member's behalf) or a minor is signing this authorization, sign and date in the designated space provided. If you are a personal representative, explain your relationship to the member and provide documentation of legal authority to act on the member's behalf. NEW DIRECTIONS'

NEW DIRECTIONS' Nondiscrimination and Accessibility Notice (ACA § 1557) New Directions Behavioral Health® ("New Directions") complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. New Directions does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. New Directions provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written infonnation in other formats (large print, audio, accessible electronic formats, other formats) o Provides free language services to people whose primary language is not English, such as: • Qualified interpreters • Infonnation written in other languages If you need these services, contact New Directions at 800 -528 -5763 (TTY!ITD services are available for hard of hearing and deaf callers). If you believe that New Directions has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with: Compliance Officer P. O. Box 6729 Leawood, KS 66206 -0729 l-855 -580 -487 l (phone) 816 -2359 (fax) compliance@ndbh. com You can file a grievance by mail, fax or email. If you need help filing a grievance, our Compliance Officer is available to help you. You can also file a civil rights complaint with the U. S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https: llocrportal. hhs. gov/ocrlportal/lobby. is. C or by mail or phone at: U. S. Department of Health and Human Services, 200 Independence Avenue SW Room 509 F, HHH Building Washington, DC 20201 800 -868 -1019, 800 -537 -7697 (TDD) Complaint fonns are available at lzttp: /lwww. hhs. gov/ocrlofflce/file/index. html.

For assistance or questions please contact HR Benefits Analyst, Terressa Galbraith At terressa. galbraith@arkansas. gov or 501 -212 -5115 Thank you for your time, Terressa Galbraith