April 14, 2003
My practice follows professional standards and
laws to protect your privacy. Federal laws require me to provide you with a
notice of my privacy practices.
This notice describes how your individual
identifiable information may be used or disclosed. Also, this notice describes
how you may get access to your individual identifiable information that is
maintained by my practice. Please read this notice and ask me any questions you
have on how I keep you information confidential.
Typically, my practice will ask for your written
permission or authorization to share or obtain information with others.
However, I may use and disclose information about you without your
authorization in the following circumstances:
1.
Treatment:
I may use your information and disclose it to manage or coordinate treatment
provided to you. For example, as your therapist I may share information with
another therapist or your physician to coordinate services.
2.
Payment:
I may use and disclose necessary information about you to obtain payment for my
services. For example, this information could include information that your
health insurance plan may require before it approves or pays for treatment
services I recommend for you.
3.
Health Care Operations:
I may need to use or disclose information for my practice activities. Examples
of these activities include:
·
quality assessment to see how well I am doing in
serving individuals, couples, and families
·
clinical supervision of staff to meet state
licensure and/or certification requirements.
·
Education and training of students and other
professionals.
·
Compliance activities to ensure I am properly
following policies, procedures, laws, regulations, and professional standards.
I may use or disclose information about you in several other circumstances in which you do not have an opportunity to agree or object. These situations include:
1. Required by Law: I may need to disclose information for judicial or other administrative proceedings. For example, I may need to disclose information in response to a court order or a Department of Social Service investigation.
2. Abuse or Neglect: I am required to disclose information if I believe that you or a family member have been a victim of abuse or neglect OR if you or a family member is abusing or neglecting another person.
3. Danger to Self or Others: I am required to take steps to prevent you harming yourself or another person.
4. Law Enforcement: Law enforcement purposes may include:
· Legal processes required by law
· Limited information requests for identification and location purposes.
· Pertaining to victims of a crime.
· In the event that a crime occurs on my premises
5. Public Health: I may be required by law to report health related information for public health activities.
6. Other Circumstances: Although not typically encountered in my practice, there are other situations when I may disclose information without your written authorization. Examples of these circumstances include providing information for research, information on inmates or military veterans, and national security activities.
For any reason other than those listed above, I will ask for your written authorization before we use or disclose information about you. Also, any authorization can be canceled any time in writing. (If you tell me you are canceling an authorization, I will have you sign a request during the current or next visit.) If cancelled, I will no longer disclose information that was allowed under that specific authorization.
Important!: Therapy notes have
special protections and I will not release or disclose therapy notes except
when required to do so by law.
I have a specific policy on the use and disclosure of therapy notes. This policy can be shared with you if you request.
Your Rights About Your Private Identifiable Information
1. Request Restrictions: You may request further restrictions on my uses and disclosures of your information. I may not be able to agree to all requested restrictions. Please let me know if you want specific restrictions on your information.
2. Different Ways to Communicate: Typically I will communicate by mailing or phoning your residence. However, you may prefer a different way for me to contact you. For example, you may request me to contact you at a specific address or phone. Please note that cell phones and e-mail may not offer confidentiality or privacy protection.
3. Right to See and Copy Information: You may see and receive copies of your information maintained in your designated record. I may charge for copying your designated record. There are situations in which I do not have to comply to your request. However, I will say in writing if I cannot comply to a request.
Please note that therapy notes are not part of your designated record. Because therapy notes are not part of your designated record, you may not have access to therapy notes.
4. Right to Request Amendment of Your Information: You may request that information about you be amended or changed. I may deny your request if I did not create the information (it was obtained from another source). Also, I may deny your request if I believe the information is correct. Denials will be written and will describe your rights for further review. If I agree to amend, I will make reasonable efforts to share with any person who may have received your information that it needs amending. Please ask me if you want to amend your information that we maintain in your designated record.
5. Listing Of Disclosures I Have Made: You may request a list of certain disclosures of your information for up to the last six (6) years. This list does not include disclosures made prior to April 14, 2003 (when the Federal Privacy Rule took effect) or disclosers related to your treatment, payment or our practice operations, and those disclosures required by law. Ask me if you desire a listing of disclosures.
6. Copy of This Notice: You may request a copy of this notice at any time. A copy is available at my office.
7. You May File a Compliant About My Privacy Practice: If you think I have violated your privacy rights described in this notice, or you want to complain to me about my privacy practices, you can contact me at:
Leo C. Thompson ThM
3404 Blue Ridge Road
Raleigh NC 27612-8013
919-781-1173
Also, you may send a written complaint to the secretary, Department of Health and Human Services. If you send a complaint, I will not take any action against you or change my treatment of you in any way.