NORTH CAROLINA NOTICE FORM

Notice of Psychologists’ 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.

I. Uses and Disclosures for Treatment, Payment, and Health Care Operations

Randall Psychological Services 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 I provide, coordinate or manage your health care and other services related to your

health care. An example of treatment would be when I consult with another health care provider, such as

your family physician, psychiatrist, or another psychologist.

- Payment is when I obtain reimbursement for your healthcare. Examples of payment are when I

disclose your PHI to your health insurer to determine eligibility or coverage. I also provide you with a

receipt that contains PHI so that you may obtain reimbursement for your health care.

- Health Care Operations are activities that relate to the performance and operation of my practice.

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 Randall Psychological Services such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

• “Disclosure” applies to activities outside of Randall Psychological Services such as releasing, transferring, or providing access to information about you to other parties.

II. Uses and Disclosures Requiring Authorization

I 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 I am asked for information for purposes outside of treatment, payment and health care operations, I will obtain an authorization from you before releasing this information. I will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes I have made about our conversation during a private, group, joint, or family counseling session, which I 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) I 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.

III. Uses and Disclosures with Neither Consent nor Authorization

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

Child Abuse: If you give me information that leads me to suspect child abuse, neglect, or death due to

maltreatment, I 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, I must do so.

Adult and Domestic Abuse: If information you give me gives me reasonable cause to believe that a disabled

adult is in need of protective services, I must report this to the Director of Social Services.

Health Oversight: The North Carolina Psychology Board has the power, when necessary, to subpoena relevant records should I 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 professional services that I have provided you and/or the records thereof, such

information is privileged under state law, and I must 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 where the evaluation is court ordered. You will be informed in advance if this is the case.

Serious Threat to Health or Safety: I 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, I am required by law to provide your mental health information relevant to the claim to your employer and the North Carolina Industrial

Commission.

IV. Patient’s Rights and Psychologist’s Duties

Patient’s Rights:

• Right to Request Restrictions –You have the right to request restrictions on certain uses and disclosures of

protected health information about you. However, I am 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 us. Upon your request, I will send your bills to another address.)

• Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. I may deny your access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. On your request, I will discuss with you the details of the request and denial process.

• Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request. On your request, I 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 for which you have neither provided consent nor authorization (as described in Section III of this Notice). On your request, I will discuss with you the details of the accounting process.

• Right to a Paper Copy – You have the right to obtain a paper copy of the notice from me upon request, even if you have agreed to receive the notice electronically.

Psychologist’s Duties:

• I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.

• I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect.

• If I revise my policies and procedures, I notify you in writing by US Mail.

V. Complaints

If you are concerned that I have violated your privacy rights, or you disagree with a decision I made about

access to your records, you can contact me at 919-368-8675 and we can talk it over. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The appropriate address is available on-line.

VI. Effective Date, Restrictions and Changes to Privacy Policy

This notice will go into effect on December 1, 2012.

• I reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that I maintain. Revised policy will be provided at the office.

This state-specific notice form describes how psychological and medical information may be used and disclosed and how a patient can get access to this information. HIPAA requires that all patients receive this notice form and return the signed acknowledgment.