Exhibit B.docx

This is a Privacy Practices Statement form for the Homeshare Residential Services program administered by the South Carolina Department of Mental Health (SCDMH). The document serves as a mandatory acknowledgment and training record for providers participating in the Homeshare program, requiring providers to confirm that they have informed all household members about confidentiality obligations and obtained their written acknowledgment. The form requires providers to document their understanding of SCDMH Privacy Practices Directive No. 837-03 and acknowledge that they have received orientation on the privacy protections applicable to information identifying SCDMH clients. Providers must sign and date the statement, with provisions for dual provider signatures when applicable, and submit the completed form to the local Homeshare Coordinator.

The statement emphasizes that client information is protected by law and that unauthorized disclosure is subject to criminal penalties. Providers are required to retain a copy of the Privacy Practices Directive for their reference and directed to contact the local Homeshare Coordinator with any questions regarding the disclosure of client information. This form functions as a compliance mechanism ensuring that all individuals working within the Homeshare residential setting understand and accept their legal and ethical obligations to maintain client confidentiality as outlined in state regulations.