of Privacy Policies and Procedures
Background Information Form (PDF*)
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Authorization to release
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Request for alternate handling of
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Notice of Privacy Policies and Procedures
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
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
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
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
Health Oversight: The
North Carolina Psychology Board has the
power, when necessary, to subpoena relevant
records should we be the focus of an
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.
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
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
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:
Asheville, NC 28802
You may also send a complaint, in
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.