NOTICE OF POLICIES AND PRACTICES TO PROTECT THE PRIVACY OF YOUR HEALTH INFORMATION
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. Disclosures for Treatment, Payment, and Health Care Operations
Transformative Life Center, LLC. and its representatives may use or disclose your protected health information (PHI), for certain treatment, payment, and health care operations with your authorization. To help clarify these terms, here are some definitions:
“PHI” refers to information in your health record that could identify you.
“Treatment, Payment, and Health Care Operations”
– Treatment is when we provide or another healthcare provider diagnoses or treats you. An example of treatment would be when we consult with another health care provider, such as your family physician or another psychologist, regarding your treatment.
– Payment is when we obtain reimbursement for your healthcare. Examples of payment are when we disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
– Health Care Operations is when we disclose your PHI to your health care service plan (for example your health insurer), or to your other health care providers contracting with your plan, for administering the plan, such as case management and care coordination.
“Use” applies only to activities within our office, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
“Disclosure” applies to activities outside of our office, such as releasing, transferring, or providing access to information about you to other parties.
“Authorization” means written permission for specific uses or disclosures.
II. Uses and Disclosures Requiring Authorization
We may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. In those instances when we are asked for information for purposes outside of treatment and payment operations, we will obtain an authorization from you before releasing this information. We will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes we have made about our conversation during a private, group, joint, or family counseling session, which we will keep separate from the rest of your medical record. These notes are given a greater degree of protection than PHI. You may revoke or modify all such authorizations (of PHI or psychotherapy notes) at any time; however, the revocation must be in writing and modification is not effective until we receive it. You may not revoke an authorization to the extent that (1) Transformative Life Center, LLC. has taken action on the consent and relies on the authorization; 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
We may use or disclose PHI without your consent or authorization in the following circumstances:
Child Abuse : Whenever our providers, in their professional capacity, have knowledge of or observe a child we know or reasonably suspect, has been the victim of child abuse or neglect, we must immediately report such to the Department of Social Services and make our relevant records available at their request.
Adult and Domestic Abuse: If our providers, in their professional capacity, have observed or have knowledge of an incident that reasonably appears to be physical abuse, abandonment, abduction, isolation, financial abuse or neglect of an elder or dependent adult, or if we are told by an elder or dependent adult that he or she has experienced these or if we reasonably suspect such, we must report the known or suspected abuse immediately to the Department of Social Services and provide information from your records relevant to a protective services investigation if requested by the Department of Social Services.
Health Oversight : The North Carolina Psychology and Medical Boards have the power, when necessary, to subpoena relevant records should an Transformative Life Center, LLC. clinician be the focus of an inquiry.
Judicial or Administrative Proceedings : If you are involved in a court proceeding and a request is made about the professional services that I have provided you, I must not release your information without 1) your written authorization or the authorization of your attorney or personal representative; 2) a court order; or 3) a subpoena duces tecum (a subpoena to produce records) where the party seeking your records provides me with a showing that you or your attorney have been served with a copy of the subpoena, affidavit and the appropriate notice, and you have not notified me that you are bringing a motion in the court to quash (block) or modify the subpoena. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court-ordered. I will inform you in advance if this is the case.
Serious Threat to Health or Safety : If you communicate to Transformative Life Center, LLC. clinicians a serious threat of physical violence against an identifiable victim, we must make reasonable efforts inform the potential victim and the police. If our clinicians have reasonable cause to believe that you are in such a condition, as to be dangerous to yourself or others, we may release relevant information as necessary to prevent the threatened danger.
Worker’s Compensation : If you file a workers' compensation claim, ACT is required by law to provide your mental health information relevant to the claim to your employer and the North Carolina Industrial Commission.
IV. Patient's Rights and Transformative Life Center, LLC.'s Duties
-Right to Request Restrictions –You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, Transformative Life Center, LLC. is not required to agree to a restriction you request.
-Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are using Transformative Life Center, LLC. services. Upon your request, we will send your bills to another address.)
-Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. Transformative Life Center, LLC. may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, we 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. Transformative Life Center, LLC. may deny your request. At your request, we 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). On your request, Transformative Life Center, LLC. will discuss with you the details of the accounting process.
-Right to a Paper Copy – You have the right to obtain a paper copy of the notice from Transformative Life Center, LLC. upon request, even if you have agreed to receive the notice electronically.
Transformative Life Center’s Duties:
-Transformative Life Center, LLC. is required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI.
-Transformative Life Center, LLC. reserves the right to change the privacy policies and practices described in this notice. Unless Transformative Life Center, LLC. notifies you of such changes, however, we are required to abide by the terms currently in effect.
*If Transformative Life Center, LLC. revises our policies and procedures, we will notify you as indicated in section VI below.
If you are concerned that I have violated your privacy rights, or you disagree with a decision I made about access to your records, you may address your concern with Transformative Life Center’s Clinical Director by phone at 704-927-5885 ,or mail. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. Any Transformative Life Center clinician can provide you with the appropriate address upon request.