I am pleased that you have considered my services for you and/or your family member(s).  It is important that you understand that counseling is an involved, and at times, difficult process.

I am an in-network provider for many insurance programs and will file your claims as a courtesy to you.  It is your responsibility to contact your insurance company to verify that they will cover services with me.  If you need assistance in this process, I will gladly help.  Deductibles and co-payments are due at the time of the service rendered.  If you do not have insurance coverage, I am happy to negotiate a payment plan and schedule with you.  Finally, I require 24 hour advanced notice in the event that you need to cancel an appointment.  If this does not occur, you will be responsible for full payment of the missed session.  Insurance companies will not reimburse for missed appointments.  I look forward to working with you and am hopeful that your experience with me will be positive and fruitful.  Below is information commensurate with the federal HIPPA guidelines that speaks to your privacy rights.

 

Notice of Privacy Practices

This notice describes how medical information about you may be disclosed and how you can get access to this information.  Please review it carefully.

 

I am required by law to protect medical information about you.

 

I am required by law to protect the privacy of medical information about you and that identifies you.  I am also required to give you the Notice of Privacy Practices, explaining my legal duties and your rights concerning your health information. I must follow the privacy practices described in this Notice while it is in effect.  If you have any questions about the information in this notice, please speak with me, or phone me at 919-601-0540.

 

 

How I may use and disclose medical information about you in certain circumstances

I use and disclose health information about you for treatment, payment, and healthcare operations.  For treatment, I may use or disclose your health information to a physician or other healthcare provider providing treatment to you.  For payment. I may use and disclose your health information to obtain payment for services I provide to you.  Regarding healthcare operations, I may use and disclose your health information in connection with my healthcare operations, for such activities as quality assessment, chart audits, and certification and licensing.

 

Your Authorization

Unless you give me a written authorization, I cannot use or disclose your health information for any reason except those described in this Notice.  If you give me authorization, you may revoke it in writing at any time.  Your revocation will not effect any disclosures already having occurred while the authorization was in effect.

 

Disclosures to You, Your Family or Friends

I must disclose your health information to you in accordance with the Patient Rights section of this Notice.  I may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you authorize me to do so.

 

Persons Involved in Your Care

I may use or disclose health information to notify, or assist others in notifying a family member, or other person responsible for your care, of your location or your general condition. If you are present, I will provide you with an opportunity to object to such disclosures of your health information prior to use or disclosure of that information.  In the event you become incapacitated or have a medical emergency, I will disclose your health information based on my professional judgment that such disclosure is directly relevant to that person’s involvement in your healthcare.

 

Marketing Health Related Services

I will not use your health information for marketing communications without your written authorization.

 

Required by Law

I may use or disclose your health information when I am required to do so by law.

 

Abuse or Neglect

I may disclose your health information to appropriate authorities if I reasonably believe that you may be the victim of abuse, neglect, domestic violence or other crimes.  I may disclose you health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

 

Client Rights

 

Access

You have the right to look at or get copies of your health information, with limited exceptions.  You may request that I provide you copies in a format other than photocopies.  I will use the format you request unless I cannot practically do so.  You must make the request in writing to obtain access to your health information.

 

Restriction

You have the right to request that I place additional restrictions on my use or disclosure of your health information.  I am not required to agree to these additional restrictions, but if I do so, I will abide by our agreement (except in an emergency).

 

Alternative Communication

You have the right to request that I communicate with you about your health information by an alternative means or to alternative locations.  You must make your request in writing.

 

Amendment

You have the right to request that we amend your health information.  Your request must be in writing, and it must explain why the information should be amended.  I may deny your request under certain circumstances.

 

Questions and Complaints

If you want more information about my privacy practices or have questions or concerns, please contact me, or the North Carolina Board of Licensed Professional Counselors at PO Box 77819, Greensboro, NC 27417, 336-217-9450.

 

If you are concerned that I may have violated your privacy rights, or if you disagree with a decision I made about the access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have me communicate with you by alternative means or alternative locations, you may complain to me or the NC Board of Licensed Professional Counselors.  You may also submit a written complaint to the US Department of Health and Human Services.  I will provide you with the address to file your complaint with the US Department of Health and Human Services upon request.

 

I support your right to the privacy of your health information.  I will not retaliate in any way if you choose to file a complaint with me, the NC Board of Licensed Professional Counselors or with the US Department of Health and Human Services.