Hippa Privacy Practices
Information about you may be used and disclosed and how you can get access to this information.
Please review it carefully.
The effective date of this notice is July 1, 2006. Information will only be released in accordance with state and federal laws and the ethics of the counseling profession. This policy describes Dominion Counseling & Consulting Services, PLLC policies related to the use and disclosure of the client’s healthcare information.
Use and disclosure of protected health information for the purposes of providing services. Providing treatment services, collecting payment, and conducting healthcare operations are necessary activities for quality care. State and federal laws allow us to use and disclose your health information for these purposes.
We may need to use or disclose health information about you to provide, manage or coordinate your care or related services, which could include consultants and potential referral sources.
Information needed to verify insurance coverage and/or benefits with your insurance carrier, to process your claims as well as information needed for billing and collection purposes. We may bill the person in your family who pays for your insurance.
We may need to use information about you to review our treatment procedures and business activity. Information may be used for certification, compliance and licensing activities.
OTHER USES OR DISCLOSURES OF YOUR INFORMATION WHICH DOES NOT REQUIRE YOUR CONSENT
There are some instances where we may be required to use and disclose information without your consent. For example, but not limited to:
Information you and/or your child or children report about physical or sexual abuse: then by North Carolina State Law, we are obligated to report this to the Department of Children and Family Services.
• If you provide information that informs us that you are in danger of harming yourself or others.
• Information to remind you of/or to reschedule appointments or treatment alternatives.
• Information shared with law enforcement if a crime is committed on our premises or against our staff or as required by law such as a subpoena or court order.
YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION
• Right to access your protected health information: You have the right to review or obtain copies of your protected health information records, with some limited exceptions. Usually the records include enrollment, billing, claims payment and case or medical management records. Your request to review and/or obtain a copy of your protected health information records must be made in writing. We may charge a fee for the costs of producing, copying, or mailing your requested information, but we will tell you the cost in advance.
• Right to amend your protected health information: If you feel that your protected health information maintained by our office is incorrect or incomplete, you may request that we amend the information. Your request must be made in writing and must include the reason you are seeking a change. If we deny your request to amend, we will notify you in writing. You have the right to submit to us a written statement of disagreement with our decision and we have the right to rebut that statement.
• Right to accounting of disclosures: You have the right to request an accounting of disclosures we have made of your protected health information. The list will not include our disclosures related to your treatment, our payment or health care operations, or disclosures made to you or with your authorization. The list may also exclude certain other disclosures, such as for national security purposes. Your request for an accounting of disclosures must be made in writing and must state a time period for which you want an accounting. This time period may not be longer than six years and may not include dates before July 1, 2006. Your request should indicate in what form you want the list (for example, on paper or electronically). The first accounting that you request within a 12-month period will be free. For additional lists within the same time period, we may charge for providing the accounting, but we will tell you the cost in advance.
• Right to request restrictions on the use and disclosure of your protected health information: You have the right to request that we restrict or limit how we use or disclose your protected health information for treatment, payment or health care operations. We may not agree to your request. If we do agree, we will comply with your request unless the information is needed for an emergency. Your request for a restriction must be made in writing. In your request, you must tell us:
1. what information you want to limit;
2. whether you want to limit how we use or disclose your information, or both;
3. to whom you want the restrictions to apply.
• Right to receive confidential communications: You have the right to request that we use a certain method to communicate with you about your mental health information or that we send this information to a certain location of the communication could endanger you. Your request to receive confidential communications must be made in writing. Your request must clearly state that all or part of the communication from us could endanger you. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
• Right to a paper copy of this notice: You have a right at any time to request a paper copy of this notice, even if you had previously agreed to receive an electronic copy.
• Right to receive changes to this notice: We reserve the right to change the terms of this notice at any time, effective for protected health information that we already have about you as well as any information that we receive in the future. We will provide you with a copy of the new notice whenever we make a material change to the privacy practices described in this notice. We will also post a copy of our current notice in our office. Anytime we make a material change to this notice, we will promptly revise and post the new notice with the new effective date.
• Right to complain: If you believe that your privacy rights have been violated, you may file a grievance with us and/or with the Secretary of the Department of Health and Human Services. All grievances to Dominion Counseling & Consulting Services, PLLC must be made in writing and sent to the privacy officer. Their information is listed at the end of this notice.
Contact information for exercising your rights: You may exercise any of the rights described above by contacting our privacy officer. They may be contacted by writing to:
Dominion Counseling & Consulting Services, PLLC.
ATTN: Privacy Officer
PO Box 1546
Huntersville, NC 28070-1546