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.