HIPAA Notification of Privacy Practices


I am committed to and follow the guidelines contained in this document in order to protect the privacy of your Protected Health Information (PHI). PHI is defined in the Privacy Rule of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act (HIPAA) of 1996 as any individually identifiable health information (either directly or indirectly identifiable), whether oral or recorded in any form or medium, that is created or received by a health care provider, health plan, or others and relates to the past, present, or future physical or mental health or condition of an individual (you); the provision of health care (e.g. mental health) to an individual (you); or the past, present, or future payment of the provision of health care to an individual (you). I provide mental health services. I create and maintain treatment records that contain individually identifiable health information about you. This Notice, among other things, concerns the privacy and confidentiality of those records and the information contained therein.

I am required by law, as well as by professional standards, to keep your health information private; to give you this notice of my privacy practices, and to let you know if I make any changes to them.

I consider all information about our work to be confidential. Your signature on the “Receipt and Acknowledgment Form”, stating that you have received and reviewed this Notice, gives me your consent to use and/or disclose your PHI for payment purposes, as needed for billing, insurance claims, and collections.


Whenever your PHI is released or obtained, it will be the minimum information necessary. I may use your PHI for purposes of providing your treatment, obtaining payment for your care and conducting health care operations. I have established policies to guard against unnecessary disclosure of your health information.

There are some situations in which the release of information without your authorization is required and/or permitted by law and professional ethics. These include:

  • Emergencies
  • Reporting the abuse, exploitation, or neglect of a minor, a dependent adult, or an elderly person.
  • Disclosures required by court order. If there is need for health oversight, the North Carolina Psychology Board has the power when necessary to subpoena relevant health records.

  • Disclosures necessary to prevent or lessen serious and imminent threat to the health and safety of a person or the public.

  • Contacting you to provide appointment reminders, or notification of schedule changes.

  • To obtain reimbursement from third parties for the care you receive from me.
    For example, I may be required by your health insurer to provide information regarding your health care status so that the insurer will reimburse you or me. Also, I may need to obtain prior approval from your insurer and may need to explain to the insurer your need for mental health services that will be provided to you.

  • At the request of reimbursement parties for the purposes of audit or investigation of benefits.

  • When required to do so by federal, state, or local law.

Other than what is stated above, I will not disclose your PHI without your informed and voluntary written authorization. If you authorize me to use or disclose your PHI, you may revoke that authorization in writing at any time.

You have the following rights regarding your PHI that I maintain:
  • Right to request restrictions. You may request restrictions on certain uses and disclosures of your PHI. You have the right to request a limit on my disclosure of your PHI for the purposes of treatment, payment, and health care operations. However, I am not required to agree to your request.
  • Right to receive confidential communications. You have the right to request that I communicate with you in a certain way. If you wish to receive confidential communications, please contact me.
  • Right to inspect and copy your health information. You have the right to inspect and copy your PHI, including billing records. If you request a copy of your PHI, I may charge a reasonable fee for copying and assembling costs associated with your request.
  • Right to amend health care information. You have the right to request that I amend your PHI, if you believe that your health information is incorrect or incomplete. That request may be made as long as the information is maintained by me. A request for an amendment of records must be made in writing to me. I may deny the request if it is not in writing or does not include a reason for the amendment. The request also may be denied if your PHI records were not created by me, if the records you are requesting are not part of my records, if the PHI you wish to amend is not part of the health information you are permitted to inspect and copy, or if, in my opinion, the records containing your health information are accurate and complete.
  • Right to an accounting. You have the right to request an accounting of disclosures of your PHI made by me for certain reasons, including reasons related to public purposes authorized or mandated by law. The request for an accounting must be made in writing. The request should specify the time period, and may not be made for periods of time in excess of seven (7) years. Accounting requests may be subject to a reasonable cost-based fee.
  • Right to a paper copy of this notice. You have a right to a separate paper copy of this Notice at any time, even if you have received this Notice previously. To obtain a separate paper copy, please contact me.
  • Right to refuse acknowledgement of this notice. You have a right to refuse toacknowledge receipt of this Notice.
  • Right to be notified of a breech. You have the right to be notified if there is a breech of unsecured PHI.



I am required by law to maintain the privacy of your health information, and to provide to you this notice of my duties and privacy practices. I am required to abide by the terms of this notice. I reserve the right to change the terms of this notice. If revised, I will provide you with a copy of the revised information. If you believe that your privacy rights have been violated, you may file a written complaint to Hope Panara, 901 Paverstone Drive, Suite 10, Raleigh, NC 27615. You may also submit a complaint to the Secretary of the U.S. Department of Health and Human Services by phone at (404) 562-7886 or in writing at: 200 Independence Avenue, SW, Room 509F, HHH Building, Washington, D.C. 20201. I cannot and will not make you waive your right to file a complaint as a condition of receiving care from me, or penalize you for filing a complaint.


Hope Panara is the designated contact person for all issues regarding privacy and your rights under the federal privacy standards. If you need or desire further information or have questions related to this notice or its contents, please contact her by phone at (919) 623-3989 or in writing at: 901 Paverstone Drive, Suite 10, Raleigh, NC 27615.


This notice is effective November 15, 2015.

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