Privacy Notice

PRIVACY NOTICE
Donna Bartlett, LCSW, LCAS, CMHt Notice of Policies and Practices to
Protect the Privacy of Your Health Information

THIS NOTICE DESCRIBES HOW PSYCHOTHERAPEUTIC 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

Your protected health information (PHI) may be disclosed for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:

• -"PHI" - information in your health record that could identify you.
• -"Treatment, Payment and Health Care Operations" -

Treatment is the provision, coordination or management of your health care and other services related to your health care. An example of treatment would be consultation with another health care provider, such as your family physician or another mental health therapist.

Payment is obtaining reimbursement for your health care. Examples of payment are when your health information is disclosed to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.

Health Care Operations are activities that relate to the performance and operation of this 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 this practice such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
• -"Disclosure" applies to activities outside of this practice group, such as releasing, transferring, or providing access to information about you to other parties.

II - Uses and Disclosures Requiring Authorization

Your health information may be used or disclosed for purposes outside of treatment, payment, and health care operations only 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 information for purposes outside of treatment, payment, and health care operations is requested, your authorization will be obtained before releasing this information. Psychotherapy notes are notes made by your therapist about your conversation during a private, group, joint, or family counseling session, and are given a greater degree of protection than your general record. They cannot be released on a general Authorization request for your medical record.

You may revoke all such authorizations at any time, provided each revocation is in writing. You may not revoke an authorization (1) after information has been released 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

Your health information may be used or disclosed without your consent or authorization in the following circumstances:

• Child Abuse - If you give information which leads your therapist to suspect child abuse, neglect, or death due to maltreatment, that information must be reported 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, your therapist must do this.
• Adult and Domestic Abuse - If you provide information that gives your therapist reasonable cause to believe that a disabled adult is in need of protective services, this must be reported to the Director of Social Services.
• Judicial or Administrative Proceedings - If you are involved in a court proceeding, and a request is made for information about the professional services provided to you and/or the records thereof, such information is privileged under state law, and must not be released 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 - Your confidential information may be disclosed to protect you or others from a serious threat of harm by you.
• Worker's Compensation - If you file a Worker's Compensation claim, I am required by law to provide your mental health information relevant to the claim to both your employer and the North Carolina Industrial Commission.

IV - Patient's Rights and Psychotherapist'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. Your request must describe in detail the restriction you are requesting. While I make every effort to honor your request, it may not be possible.

Right to Receive Confidential Communications by Alternative Means and at Alternative Locations - You have the right to request and receive confidential communications of Protected Health Information by alternative means and at alternative locations. For example, you may not want a family member to know that you are seeing a therapist. If you request it in writing, correspondence to you may be sent to another address.

Right to Inspect and Copy - You have the right to inspect or obtain a copy (or both) of health information in the mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. Your therapist may deny your access under certain circumstances. On your request, your therapist 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. Your therapist may deny your request. If you wish, your therapist 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). If you wish, your therapist will discuss with you the details of the accounting process.

Each of the above rights may be exercised through a written request signed by you or your representative.

Provider's Duties
Your Provider is required by law to maintain the privacy of PHI and to provide you with a notice of legal duties and privacy practices with respect to PHI.

Your Provider reserves the right to change the privacy policies and practices described in this notice. Unless you are notified of such changes, however, the current terms will apply.

If policies and procedures are revised, you will be informed of these revisions prior to any release of PHI.

V - COMPLAINTS

If you are concerned that your privacy rights have been violated, or you disagree with a decision about access to your records, you may file a written complaint to the Secretary of the U.S. Department of Health and Human Services in Washington DC within 180 days of a violation of your rights.

VI - Effective Date, Restrictions and Changes to Privacy Policy

This notice will go into effect on March 1, 2010.

If I make material changes to these privacy practices, I will provide copies of revised Notices to all active clients. Copies of the most recent Notice may be obtained from me directly.