Notice of Our Policies and Practices to Protect the Privacy of
Your Health Information

THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Uses and Disclosures for Treatment, Payment, and Health Care Operations
We may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. 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 (ex. consulting with another health care provider, such as your family physician.)
• Payment is when we obtain reimbursement for your healthcare (ex. disclosing your PHI to your health insurer to obtain reimbursement for services.)
• Health Care Operations are activities that relate to the performance and operation of our practice (ex. quality assessment and improvement activities.)
• Use applies only to activities within our office, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
• Disclosure applies to activities outside of our office, such as releasing, transferring, or providing access to information about you to other parties.

Uses and Disclosures Requiring Authorization

We may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An authorization is written permission above and beyond the general consent that permits only specific disclosures. In those instances when we are asked for information for purposes outside of treatment, payment and health care operations, we will obtain an authorization from you before releasing this information. We will also need to obtain an authorization before releasing you psychotherapy notes. Psychotherapy notes are notes your counselor makes about the content of a counseling session, which are 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 authorization (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, and the law provides the insurer the right to contest the claim under the policy.

Uses and Disclosures with Neither Consent nor Authorization

We may use or disclose PHI without your consent or authorization in the following circumstances:

• Child Abuse: If you give your counselor information which leads him/her to suspect child abuse, neglect, or death due to maltreatment, he/she must report such information to the county Department of Social Services. If asked by the Director of Social Services to turn over information from your records relevant to a child protective services investigation, we must do so.
• Adult and Domestic Abuse: If information you provide gives your counselor reasonable cause to believe that a disabled adult is in need of protective services, he/she must report this to the Director of Social Services.
• Health Oversight: The North Carolina Psychology Board (and other professional boards) have the power to subpoena relevant records should your counselor be the focus of an inquiry.
• Judicial or Administrative Proceedings: If you are involved in a court proceeding, and a request is made for information about the services that we have provided you and/or the records thereof, such information is privileged under state law, and we may not release this information without your written authorization, or a court order. (This privilege does not apply when you are being evaluated for a third party or the evaluation is court ordered. You will be informed in advance if this is the case.)
• Serious Threat to Health or Safety: Your counselor may disclose your confidential information to protect you or others from a serious threat of harm by you.
• Worker’s Compensation: If you file a workers’ compensation claim, we are required by law to provide your mental health information relevant to the claim to your employer and the North Carolina Industrial Commission.

Patient’s Rights and Counselor’s Duties

• Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, your counselor 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 seeing a counselor. Upon your request, we will send your bills to another address.)