Meigie Johnson, LCSW

Notice of Privacy Practices

 

This notice is effective on April 14, 2003

 

 

THIS NOTICE DESCRIBES HOW CONFIDENTIAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. 

 

PLEASE REVIEW IT CAREFULLY.

 

I AM REQUIRED BY LAW TO PROTECT CONFIDENTIAL INFORMATION ABOUT YOU

 

I am required by law to protect the privacy of all information about you and all information that identifies you.  All information I obtain from our work together is confidential.

 

I am also required by law to provide you with this Notice of Privacy Practices explaining my legal duties and privacy practices with respect to confidential information.  I am legally required to follow the terms of the Notice.  In other words, I am only allowed to use and disclose confidential information in the manner that I have described in this Notice.

 

I may change the terms of this Notice in the future.  I reserve the right to make changes and to make a new Notice.  If I make changes to the Notice, I will:

The rest of this Notice will:

 

If, at any time, you have questions about information in this Notice or about my privacy policies, procedures or practices, you can let me know during one of our sessions or by telephone.

 

 

 

 

 

I MAY USE AND DISCLOSE CONFIDENTIAL INFORMATION ABOUT YOU IN SEVERAL CIRCUMSTANCES

1.)    Written Authorization

     In most circumstances information either written or verbal cannot be disclosed to anyone without your written consent.  A request for me to disclose information might come from you or can be initiated by me.  In either case I cannot give any information, including your status as my client, without your written consent.  A copy of any Release of Information form that you sign will be provided upon your request.

You can revoke a consent to disclose information about you at any time.  This revocation, however, is not effective to the extent that I have already taken action in reliance on the original authorization.

 

2.)    Exceptions to Confidentiality

There are situations mandated by State and/or Federal law where I can disclose confidential information about you without your consent:

·        Threat of suicide or harm to self:  I am required to provide protection for someone at risk

for suicide or harming him/herself.  This could include notifying law enforcement, another mental health provider, or any other person to ensure protection.

·        Threat of homicide or harm to another person:  I am required to do whatever is necessary

to prevent or lessen a client’s threat to harm someone else.  This could include notifying law enforcement or any other person necessary to ensure protection.

·        Abuse and Neglect:  If I have any suspicion that a child under 18 is being physically abused,

sexually abused, or neglected I am required to report this to the appropriate authority.  Likewise, if I have any suspicion that a disabled adult is being physically abused, sexually abused, or neglected I am required to report this to the appropriate authority.

·        Court Proceedings:  I may disclose confidential information about you if a judge orders me to do so, i.e. court order.

 

3.)      Release of Information for Insurance purposes:  Filing for benefits for psychotherapy services with your medical insurance requires a clinical diagnosis code.  If you are filing yourself for your benefits this code will be provided to you on your receipt for each session.  In the event that either you or I am filing for your insurance benefits, I will ask you to sign an authorization form indicating that I can release information necessary to process the claim including your diagnosis code.  I will also discuss your diagnosis code with you.

Some insurance providers require me to complete Outpatient Treatment Reports to determine

that your psychotherapy services are medically necessary by their criteria.  Disclosure of this information is covered in the consent allowing me to file for your insurance benefits.  I will inform you, however, when such a report is required and will give you a copy of the report upon your request.

 

4.)    Consultation with other mental health providers:  As a part of providing services to my clients, I

do get consultation with other mental health providers.  I do this making every effort not to disclose identifying information and these providers are also bound by confidentiality.  Consulting other providers in this manner is an established practice in the profession of Clinical Social Work.

            Please let me know if you have any questions or concerns about my using consultation as a part of my practice.

YOU HAVE RIGHTS WITH RESPECT TO INFORMATION ABOUT YOU

 

You have several rights with respect to information about you that I obtain during our work together.  This section of the Notice will briefly explain each of these rights.  I will be glad to discuss these rights with you at anytime.

1.  Right to a copy of this Notice

     You have a right to a copy of my Notice of Privacy Practices at any time.  In addition, a copy of this Notice will be posted in my office.

2.  Right of access to inspect and copy

      You have a right to inspect (which means see or review) and receive a copy of information in your chart with the exception of psychotherapy notes.  If you would like to inspect or receive a copy of information in your chart, you must provide me with a written request.  I may deny your request in certain circumstances.  If I deny your request, I will explain my reason for doing so in writing.  I will also inform you in writing if you have the right to have our decision reviewed by another person.

       If you would like a copy of the information, I will charge you a fee of $.07 per page to cover the costs of the copy.

3.  Right to have chart information amended

      You have the right to have me amend ( which means correct or supplement) information in your chart with the exception of psychotherapy notes.  If you believe that I have information that is either inaccurate or incomplete, I may amend the information to correct the problem and notify others who have copies of the inaccurate or incomplete information.  Requests to amend information in your chart must be received in writing.

      I may deny your request in certain circumstances.  If I deny your request, I will explain my reason for doing so in writing.  You will also have the opportunity to send me a statement explaining why you disagree with my decision to deny your amendment request and I will share your statement whenever I disclose information in the future.

4.  Right to an accounting of disclosures I have made

      You have the right to receive an accounting (which means a detailed listing) of disclosures that I have made for the previous six years.  This accounting will not include disclosures made for the purposes of filing for your insurance benefits.  It will also not include disclosures made prior to April 14, 2003.  Requests for a copy of this accounting form must be made in writing.

YOU MAY FILE A COMPLAINT ABOUT MY PRIVACY PRACTICES

If you believe that your privacy rights have been violated or if you are dissatisfied with my privacy policies or procedures you can talk with me at any time.  You have the right to file a complaint with the federal government by contacting:  Secretary of Health and Human Services, US Dept. of Health and Human Services, 200 Independence Ave., SW, Washington, DC  20201.  You can also file a complaint with the NC Social Work Certification and Licensure Board, PO Box 1043, Asheboro, NC  27204  (T:  (336) 625-1679)

            My signature indicates that I have reviewed the Notice of Privacy Practices.

 

            Signature:  __________________________________________Date:  ____________________