Nancy D. Lloyd, Ph.D.
4609 Western Blvd., Ste. #1
Raleigh, N.C. 27606
(919) 848-1969
Fax (919) 235-0909
NORTH CAROLINA NOTICE FORM
Notice of Psychologists’
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 may use or disclose your protected
health information (PHI), for treatment, payment, and health care
operations purposes with your consent.
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 I provide, coordinate or manage your health care and other services
related to your health care. An example of treatment would be when I consult
with another health care provider, such as your family physician or another
psychologist.
- Payment
is when I obtain reimbursement for your healthcare. Examples of payment are when I disclose your PHI 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 my 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
my [office, clinic, practice group, etc.] such as sharing, employing, applying,
utilizing, examining, and analyzing information that identifies you.
·
“Disclosure” applies to activities
outside of my [office, clinic, practice group, etc.], such as releasing,
transferring, or providing access to information about you to other parties.
I
may use or disclose PHI for purposes outside of treatment, payment, and health
care operations 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 I
am asked for information for purposes outside of treatment, payment and health
care operations, I will obtain an authorization from you before releasing this
information. I will also need to obtain
an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes I have
made about our conversation during a private, group, joint, or family
counseling session, which I have kept separate from the rest of your medical
record. These notes are given a greater
degree of protection than PHI.
You
may revoke all such authorizations (of PHI or psychotherapy notes) at any time,
provided each revocation is in writing. You may not revoke an authorization to the
extent that (1) I have relied on that 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.
I
may use or disclose PHI without your consent or authorization in the following
circumstances:
§
Child Abuse: If you give me information which leads
me to suspect child abuse, neglect, or death due to maltreatment, I must report
such information 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, I must do so.
§ Adult and Domestic Abuse: If information you give me gives me reasonable cause to believe that a disabled adult is in need of protective services, I must report this to the Director of Social Services.
§
Health Oversight: The North Carolina Psychology Board has
the power, when necessary, to subpoena relevant records should I be the focus
of an inquiry.
·
Judicial or Administrative Proceedings: If you are involved in a court
proceeding, and a request is made for information about the professional
services that I have provided you and/or the records thereof, such information
is privileged under state law, and I must not release this information 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: I may disclose your confidential
information to protect you or others from a serious threat of harm by you.
·
Worker’s Compensation: If you file a workers’ compensation
claim, I am required by law to provide your mental health information relevant
to the claim to your employer and the North Carolina Industrial
Commission.
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. However, I am 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 seeing me. Upon your
request, I 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. I may
deny your access to PHI under certain circumstances, but in some cases, you may
have this decision reviewed. On your request, I 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. I may deny
your request. On your request, I 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, I 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 me upon request, even if you have agreed to receive the
notice electronically
Psychologist’s
Duties:
·
I am
required by law to maintain the privacy of PHI and to provide you with a notice
of my legal duties and privacy practices with respect to PHI.
·
I reserve
the right to change the privacy policies and practices described in this
notice. Unless I notify you of such changes, however, I am required to abide by
the terms currently in effect.
·
If I revise
my policies and procedures, I will notify you at our next therapy session if
you are an active patient ( therapy session within the past 60 days or an
appointment pending.). Otherwise, You
will only be notified if there is any activity involving your record.
·
If you have
questions about this notice, disagree with a decision I make about access to
your records, or have other concerns about your privacy rights, you may contact
Nancy D. Lloyd, Ph.D. at (919) 848-1969
for further discussion or additional information.
If you believe
that your privacy rights have been violated and wish to file a complaint with me/my office, you may send your written
complaint to me at the address at the top of this document. You may also send a
written complaint to the Secretary of the U.S. Department of Health and Human
Services. The person listed above can
provide you with the appropriate address upon request.
You have
specific rights under the Privacy Rule.
I will not retaliate against you for exercising your right to file a
complaint.
This notice will
go into effect on April 14, 2003.
I reserve the
right to change the terms of this notice and to make the new notice provisions
effective for all PHI that I maintain.
I will provide you with a revised notice by discussing it with you at
our next therapy session if you are an active patient (seen in therapy within
the past 60 days or have a pending appointment.. If you are not an active patient you will be notified of any
changes should there be any activity regarding your record.