HIPAA Statement of Privacy Practices and Client Rights
Sarah E. Stein-Wolf LCMHC RPT
SW Counseling PLLC
1310 E. Arlington Blvd, Ste A
Greenville, NC 27858
Privacy Officer: Sarah E. Stein-Wolf
SW Counseling PLLC will use commercially reasonable efforts to always respond and resolve any problem or question as promptly as possible.
Effective Date: May 29, 2018
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
We are committed to maintaining the confidentiality of your health information that we maintain about you. This notice provides you with information about your rights and our legal duties and practices with respect to the privacy of protected health information. This notice also discusses the uses and disclosures we may make of your protected health information. It also describes your rights and our legal obligations. If you have any questions about this Notice, please contact our Privacy Officer listed above.
“Protected Health Information” includes any identifiable information that we obtain from you or others that relates to your past, present or future health care and treatment or the payment for your health care and treatment. We make a record of the clinical care we provide and may receive such records from others. We use these records to provide or enable other health care providers to provide quality care, to obtain payment for services provided to you as allowed by your health plan and to enable us to meet our professional and legal obligations to operate this practice properly. We reserve the right to change the terms of this notice and to make the revised notice effective for all protected health information we maintain. You may request a paper copy of the most current privacy notice from our office.
A. Permitted Uses and Disclosures of Your Health Information
Our practice collects health information about you and stores it in a chart and on a computer. This is your clinical record. We will disclose health information about you when required or permitted to do so by federal, state or local law. The law permits us to use or disclose your health information for the following purposes:
1. Treatment. We use clinical information about you to provide care. We disclose information to our employees and others who are involved in providing the care you need. For example, we may share your information with other physicians or other providers who will provide services that we do not provide.
2. Payment. We use and disclose clinical information about you to facilitate and obtain payment for the services we provide, including to determine eligibility, coverage or benefit responsibilities under your insurance coverage. For example, the information on claims forms sent to us may include information that identifies you as well as your diagnosis and the procedures and supplies used.
3. Health Care Operations. We may use and disclose health information about you to operate this practice including for quality assurance activities, underwriting, business management and other general administrative activities. For example, we may use and disclose this information to review and improve the quality of care we provide, or the competence and qualifications of our professional staff. Or we may use and disclose this information to get your health plan to authorize services or referrals. We may also use and disclose this information as necessary for professional reviews, legal services and audits, including fraud and abuse detection, compliance programs and business planning and management. We may also share your information with our "business associates," such as any billing service that may perform administrative services for us. We have a written contract with any business associates that contains terms requiring them and their subcontractors to protect the confidentiality and security of your protected health information.
4. Notification and Communication With Family. We may disclose your health information to notify or assist in notifying a family member, your personal representative or another person responsible for your care about your location, your general condition or, unless you had instructed us otherwise, in the event of your death. We may also disclose information to someone who is involved with your care or helps pay for your care. If you are able and available to agree or object, we will give you the opportunity to object prior to making these disclosures, although we may disclose this information in a disaster even over your objection if we believe it is necessary to respond to the emergency circumstances. If you are unable or unavailable to agree or object, our health professionals will use their best judgment in communication with your family and others.
5. Marketing. Provided we do not receive any payment for making these communications, we may contact you to give you information about products or services related to your treatment, case management or care coordination, or to direct or recommend other treatments, therapies, health care providers or settings of care that may be of interest to you. We may similarly describe products or services provided by this practice and tell you which health plans this practice participates in. We will not otherwise use or disclose your clinical information for marketing purposes or accept any payment for other marketing communications without your prior written authorization. The authorization will disclose whether we receive any compensation for any marketing activity you authorize, and we will stop any future marketing activity to the extent you revoke that authorization.
6. Sale of Health Information. We will not sell your health information without your prior written authorization. The authorization will disclose that we will receive compensation for your health information if you authorize us to sell it, and we will stop any future sales of your information to the extent that you revoke that authorization.
7. As Required by Law and to Report Abuse. As required by law, we will use and disclose your health
information, but we will limit our use or disclosure to the relevant requirements of the law. When the law requires us to report abuse, neglect or domestic violence, or respond to judicial or administrative proceedings, or to law enforcement officials, we will further comply with the requirement set forth below concerning those activities.
8. Public Health Activities. We may, and are sometimes required by law, to disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability; reporting child, elder or dependent adult abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration problems with products and reactions to medications; and reporting disease or infection exposure. When we report suspected elder or dependent adult abuse or domestic violence, we will inform you or your personal representative promptly unless in our best professional judgment, we believe the notification would place you at risk of serious harm or would require informing a personal representative we believe is responsible for the abuse or harm.
9. Judicial and Administrative Proceedings. We may, and are sometimes required by law, to disclose your health information in the course of any administrative or judicial proceeding to the extent expressly authorized by a court or administrative order. We may also disclose information about you in response to a subpoena, discovery request, or other lawful process if reasonable efforts have been made to notify you of the request and you have not objected, or if your objections have been resolved by a court or administrative order.
10. Law Enforcement. We may, and are sometimes required by law, to disclose your health information to law enforcement officials in response to a court order, subpoena, warrant, summons or similar process.
11. Coroners and Medical Examiners. We may, and are often required by law, to disclose your health information to coroners in connection with their investigations of deaths.
12. Public Safety. We may, and are sometimes required by law, to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public.
13. Specialized Government Functions. We may disclose your health information for military or national security purposes or to correctional institutions or law enforcement officers that have you in their lawful custody.
B. Use or Disclosure of Your Health Information Requiring Your Consent
Except as described in this Notice of Privacy Practices, this practice will, consistent with its legal obligations, not use or disclose health information which identifies you without your written authorization. If you do authorize this practice to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time. If you revoke your authorization, we will no longer use or disclose health information about you for the reasons covered by your written authorization, except to the extent that we have already taken action in reliance upon your authorization.
1. Psychotherapy Notes. We will not use or disclose your psychotherapy notes without your prior written authorization except for the following: 1) use by the originator of the notes for your treatment, 2) for training our staff, students and other trainees, 3) to defend ourselves if you sue us or bring some other legal proceeding, 4) if the law requires us to disclose the information to you or the Secretary of HHS or for some other reason, 5) in response to health oversight activities concerning your therapist, 6) to avert a serious and imminent threat to health or safety, or 7) to the coroner or medical examiner after you die. To the extent you revoke an authorization to use or disclose your psychotherapy notes, we will stop using or disclosing these notes.
2. Sale of Protected Health Information. We must obtain your authorization prior to selling your health information. If we obtain financial remuneration for such sale, we must disclose that to you in the authorization.
3. Marketing. We must obtain your authorization prior to using or disclosing your health information for marketing purposes in most situations. If we will obtain financial remuneration for such marketing, we must disclose that to you in the authorization.
C. Your Right Concerning Your Health Information
1. Right to Request Restrictions. You have the right to request restrictions on certain uses and disclosures of your health information by a written request specifying what information you want to limit, what limitations on our use or disclosure of that information you wish to have imposed and to whom you want the limited to apply. If you tell us not to disclose information to your commercial health plan concerning health care items or services for which you paid for in full or out of-pocket, we will abide by your request, unless we must disclose the information for treatment or legal reasons. We reserve the right to accept or reject any other request.
2. Right to Request Confidential Communications. You have the right to request that you receive your health information in a specific way or at a specific location. For example, you may ask that we send information to a particular e-mail account or to your work address. We will comply with all reasonable requests submitted in writing to our Privacy Contact which specify how or where you wish to receive these communications.
3. Right to Inspect and Copy. You have the right to inspect and copy your health information, with limited exceptions. To access your information, you must submit a written request detailing what information you want access to, whether you want to inspect it or get a copy of it, and if you want a copy, your preferred form and format. We will provide copies in your requested form and format if it is readily producible, or we will provide you with an alternative format you find acceptable, or if we can’t agree and we maintain the record in an electronic format, your choice of a readable electronic or hardcopy format. We will also send a copy to any other person you designate in writing. We will charge a reasonable fee which covers our costs for labor, supplies, postage, and if requested and agreed to in advance, the cost of preparing an explanation or summary. We may deny your request under limited circumstances. If we deny your request, you may request that the denial be reviewed.
4. Right to Amend or Supplement. You have a right to request that we amend your health information that you believe is incorrect or incomplete. You must make a request to amend in writing, and include the reasons you believe the information is inaccurate or incomplete. Any agreed upon correction to your health information will be included as an addition to, and not a replacement of, already existing records. We are not required to change your health information, and will provide you with information about our denial and how you can disagree with the denial. We may deny your request if you ask us to amend information that (a) is not part of the health information kept by us; (b) was not created by us, unless the person or entity that created the information is no longer available to make the amendment, (c) is not part of the information which you would be permitted to inspect and copy or (d) is accurate and complete as is. If we deny your request, you may submit a written statement of your disagreement with that decision, and we may, in turn, prepare a written rebuttal. All information related to any request to amend will be maintained and disclosed in conjunction with any subsequent disclosure of the disputed information.
5. Right to an Accounting of Disclosures. You have a right to receive an accounting of disclosures of your health information made by this practice in the six years prior to the date that the accounting is requested (or shorter period as requested). However, we do not have to account for the disclosures provided (a) to carry out treatment, payment or health care operations, (b) made to you or pursuant to your written authorization, (c) for national security or intelligence operations or (d) to corrections institutions or law enforcement officials. Your first request for an accounting in any 12 month period shall be provided without charge. A reasonable fee shall be imposed for each subsequent request for an accounting within the same 12 month period.
6. Right to Breach Notification. In the case of a breach of unsecured protected health information, we will notify you as required by law.
D. Business Associates Disclosures
HIPAA requires that I ensure that all those performing ancillary administrative service for my practice and refers to these people as “Business Associates” sign and enter into a HIPAA compliant Business Associate Agreement so that your privacy is ensured at all times.
E. Privacy Contact
If you would like to have a more detailed explanation of these rights or if you would like to exercise one or more of these rights, contact our Privacy Officer listed at the top of this Notice of Privacy Practices.
Complaints about this Notice of Privacy Practices or how this practice handles your health information should be directed to our Privacy Officer listed at the top of this Notice of Privacy Practices. If you are not satisfied with the manner in which this office handles a complaint, you may submit a formal complaint to: (U.S. Department of Health and Human Services Office for Civil Rights). The complaint form may be found at You will not be penalized in any way for filing a complaint.
Statement of Client Rights
Any involvement with SW Counseling PLLC is completely voluntary.
I have the right to receive high-quality service, to be treated with respect and courtesy, and to be served without discrimination.
I have the right to decline to participate with any intervention at any time, and I may decline to answer questions at any time.
I have the right to discuss my services with staff to determine if it is working, and to express questions or complaints if needed. I may also request a change of staff if available, and if this is not available, I have the right to request referral without retaliation by SW Counseling PLLC.
I understand that I may file a grievance for misconduct to the North Carolina Board of Clinical Mental Health Counseling. You may submit a complaint to: NCBLCMHC Post Office Box 77819 Greensboro, NC 27417; for overnight or special delivery: 7D Terrace Way Greensboro NC 27403. Phone: 844-622-3572; Email: firstname.lastname@example.org. I understand that my information will be kept private and confidential, with the exception to legal/ethical obligation to report safety concerns (danger to self/others), order by the court, or subpoena.
I may have access to my records by written request to SW Counseling, PLLC.
In accordance with GS 122C-51, it is the policy of the State to assure basic human rights to each client of a facility. These rights include the right to dignity, privacy, humane care, and freedom from mental and physical abuse, neglect, and exploitation. Each facility shall assure to each client the right to live as normally as possible while receiving care and treatment.
It is further the policy of this State that each client who is admitted to and is receiving services from a facility has the right to treatment, including access to medical care and habitation, regardless of age or degree of mental illness, developmental disability, or substance abuse. Each client has the right to an individualized written treatment or habitation plan setting forth a program to maximize the development or restoration of his capabilities.
Statement of Client Rights with Release of Protected Health Information (PHI)
I understand that signing any consent to release PHI is voluntary.
I understand that I have the right to revoke any authorization, at any time, by sending a written notification to the office at the top of this form.
I understand that my revocation will not be effective to the extend that action has been taken in reliance on the authorization or if the authorization was obtained as a condition of obtaining insurance coverage, and the insurer has a legal right to contest a claim.
I understand that my mental health provider may not condition services upon my signing an authorization, unless these services are provided to me for the purpose of creating health information for a third party.
I understand that information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient of this information, and no longer protected by the HIPAA Privacy Rule.
I understand that SW Counseling, PLLC is not liable for any third-party disclosure of PHI pursuant to any authorization. I understand that the authorization to release PHI does not authorize my mental health provider to discuss my health information with anyone other than the person/agency specified on my release form.