EAGLES WING’S COUNSELING SERVICES, LLC
“Notice of Privacy Practices” (HIPPA)
THIS NOTICE INVOLVES YOUR PRIVACY RIGHTS
AND DESCRIBES HOW INFORMATION ABOUT YOU MAY BE DISCLOSED,
AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
As a rule, I will disclose no information about you, or the fact that you are my patient, without your
written consent. Your client file describes the services provided to you and contains the
dates of our sessions, your diagnosis, functional status, symptoms, prognosis and progress, and any
psychological testing reports. Health care providers are legally allowed to use or disclose records or
information for treatment, payment, and health care operations purposes. However, I do not routinely
disclose information in such circumstances, so I will require your permission in advance, either through
your consent at the onset of our relationship (by signing the attached general consent form), or through
your written authorization at the time the need for disclosure arises. You may revoke your permission, in
writing, at any time, by contacting me.
II. “Limits of Confidentiality”
Possible Uses and Disclosures of Mental Health Records without Consent or Authorization
There are some important exceptions to this rule of confidentiality – some exceptions created voluntarily
by my own choice, [some because of policies in this office/agency], and some required by law. If you wish
to receive mental health services from me, you must sign the attached form indicating that you
understand and accept my policies about confidentiality and its limits. We will discuss these issues now,
but you may reopen the conversation at any time during our work together.
I may use or disclose records or other information about you without your consent or authorization in the
following circumstances, either by policy, or because legally required:
· Emergency: If you are involved in a life-threatening emergency and I cannot ask your permission, I will
share information if I believe you would have wanted me to do so, or if I believe it will be helpful to you.
· Child Abuse Reporting: If I have reason to suspect that a child is abused or neglected, I am required by
Virginia law to report the matter immediately to the North Carolina Department of Social Services.
· Adult Abuse Reporting: If I have reason to suspect that an elderly or incapacitated adult is abused,
neglected or exploited, I am required by Virginia law to immediately make a report and provide relevant
information to the North Carolina Department of Social Services.
· Health Oversight: North Carolina law requires that licensed therapists report misconduct by a health
care provider of their own profession. By policy, I also reserve the right to report misconduct by health.
care providers of other professions. By law, if you describe unprofessional conduct by another mental
health provider of any profession, I am required to explain to you how to make such a report. If you are
yourself a health care provider, I am required by law to report to your licensing board that you are in
treatment with me if I believe your condition places the public at risk. North Carolina Licensing Boards
have the power, when necessary, to subpoena relevant records in investigating a complaint of provider
incompetence or misconduct.
· Court Proceedings: If you are involved in a court preceding and a request is made for information about
your diagnosis and treatment and the records thereof, such information is privileged under state law, and
I will not release information unless you provide written authorization or a judge issues a court order. If I
receive a subpoena for records or testimony, I will notify you so you can file a motion to quash (block) the
subpoena. However, while awaiting the judge’s decision, I am required to place said records in a sealed
envelope and provide them to the Clerk of Court. In civil court cases, therapy information is not protected
by patient-therapist privilege in child abuse cases, in cases in which your mental health is an issue, or in
any case in which the judge deems the information to be “necessary for the proper administration of
justice.” Protections of privilege may not apply if I do an evaluation 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: Under North Carolina law, if I am engaged in my professional duties
and you communicate to me a specific and immediate threat to cause serious bodily injury or death, to an
identified or to an identifiable person, and I believe you have the intent and ability to carry out that threat
immediately or imminently, I am legally required to take steps to protect third parties. These precautions
may include 1) warning the potential victim(s), or the parent or guardian of the potential victim(s), if
under 18, 2) notifying a law enforcement officer, or 3) seeking your hospitalization. By my own policy, I
may also use and disclose medical information about you when necessary to prevent an immediate,
serious threat to your own health and safety. If you become a party in a civil commitment hearing, I can
be required to provide your records to the magistrate, your attorney or guardian ad litem, or law
enforcement officer, whether you are a minor or an adult.
· Workers Compensation: If you file a worker’s compensation claim, I am required by law, upon request,
to submit your relevant mental health information to you, your employer, the insurer, or a certified
· Records of Minors: North Carolina has a number of laws that limit the confidentiality of the records of
minors. For example, parents, regardless of custody, may not be denied access to their child’s records
Other circumstances may also apply, and we will discuss these in detail if I provide services to minors.
Other uses and disclosures of information not covered by this notice or by the laws that apply to me will
be made only with your written permission.
III. Patient’s Rights and Provider’s Duties:
· Right to Request Restrictions-You have the right to request restrictions on certain uses and disclosures
of protected health information about you. You also have the right to request a limit on the medical
information I disclose about you to someone who is involved in your care or the payment for your care. If
you ask me to disclose information to another party, you may request that I limit the information I
disclose. However, I am not required to agree to a restriction you request. To request restrictions, you must make your request in writing, and tell me: 1) what information you want to limit; 2) whether you
want to limit my use, disclosure or both; and 3) to whom you want the limits to apply.
· 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. You may also request that I contact you only
at work, or that I do not leave voice mail messages.) To request alternative communication, you must
make your request in writing, specifying how or where you wish to be contacted.
· Right to an Accounting of Disclosures – 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 written request, I will discuss with you the details of the accounting process
. · Right to Inspect and Copy – In most cases, you have the right to inspect and copy your medical and
billing records. To do this, you must submit your request in writing. If you request a copy of the
information, I may charge a fee for costs of copying and mailing. I may deny your request to inspect and
copy in some circumstances. I may refuse to provide you access to certain psychotherapy notes or to
information compiled in reasonable anticipation of, or use in, a civil criminal, or administrative
· Right to Amend – If you feel that protected health information I have about you is incorrect or
incomplete, you may ask me to amend the information. To request an amendment, your request must be
made in writing, and submitted dot me. In addition, you must provide a reason that supports s your
request. I may deny your request if you ask me to amend information that: 1) was not created by me; I will
add your request to the information record; 2) is not part of the medical information kept by me; 3) is not
part of the information which you would be permitted to inspect and copy; 4) is accurate and complete.
· Right to a copy of this notice – You have the right to a paper copy of this notice. You may ask me to give
you a copy of this notice at any time. Changes to this notice: I reserve the right to change my policies
and/or to change this notice, and to make the changed notice effective for medical information I already
have about you as well as any information I receive in the future. The notice will contain the effective date
. A new copy will be given to you or posted in the waiting room. I will have copies of the current notice
available on request.
Complaints: If you believe your privacy rights have been violated, you may file a complaint. To do this,
you must submit your request in writing to my office. You may also send a written complaint to the U.S.
Department of Health and Human Services.