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Assessment Forms

Notice of Privacy Policies and Procedures


Background Information Form (PDF*)

Patient registration form (PDF*)

Authorization to release protected health information (PDF*)

Request for alternate handling of health information (PDF*)

Request for accounting for disclosures of health information (PDF*)

*You will need Adobe Acrobat to open the above PDF forms. If you do not have it, you can download it for free from Adobe's website by clicking here.


Notice of Privacy Policies and Procedures


The law requires us to protect your health information, give you this notice, and follow the guidelines in this notice. The practices described in this notice may change at any time. You can ask for an updated copy of our Notice of Privacy Practices at any time.

We feel very strongly about the need to protect your health records. We use or share only the information that is necessary. When others request it, our policy is to ask your permission before we share your records.

In some cases, we do not have to ask your permission to use or share your health records. An example of each of these cases is listed below.

  • Child Abuse: If you give us information that leads us to suspect child abuse, neglect, or death due to maltreatment, we 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, we must do so.

  • Adult and Domestic Abuse: If information you give us gives us reasonable cause to believe that a disabled adult is in need of protective services, we must report this to the Department of Social Services.

  • Health Oversight: The North Carolina Psychology Board has the power, when necessary, to subpoena relevant records should we 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 we have provided you and/or the records thereof, such information is privileged under state law, and we 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: We 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, we are required by law to provide your mental health information relevant to the claim to your employer and the North Carolina Industrial Commission.

When you give us permission to use or share the information in your health records, you may change your mind. You should ask us in writing if you want to cancel your permission. We will follow your instructions except where we have already shared your records. You may not be able to cancel your permission if it was given for you to get insurance.

You need to know that you have certain rights. These rights are listed below.

  • You have a right to ask us for a paper copy of this notice at any time.

  • You may ask us not to use or share your records. We will try to honor your request, but we may not be able to.

  • You may not want us to call you at home or send mail to you at your home address. If this is the case, you may ask us to use another phone number or address.

  • You may look at and get a copy of certain health records we keep about you. You may have to pay for these copies.

  • You may think information in your health record is not correct. You may ask us to make changes.

  • You may ask for a list of the times we have shared your health records. The list will not include all of the times records have been shared.

To find out how you can exercise one of the rights listed above, you may contact us at the address or telephone number listed in our contact information

If you feel we have not protected the privacy of your health records, you can complain. This is your right. You will not be punished or treated badly if you complain.

If you have questions or concerns or want to make a complaint about how we use or share your health record, contact the office listed below:

Privacy Officer
P.O. Box 1543
Asheville, NC  28802

You may also send a complaint, in writing, to:
U.S. Department of Health and Human Services
200 Independence Avenue, S .W.
Washington, DC 20201

We will explain more about this Notice if you ask us.

This notice went into effect on April 14, 2003. We reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that we maintain.

Mountain Memory Assessment
56 College Street, Suite 204
Asheville, North Carolina 28801  | 
(828) 545-7776

© 2006-08 Mountain Memory Assessment, All Rights Reserved