Privacy Notice
Policies & Practices to Protect the Privacy of Your Personal Information
This notice describes how information in your mental health file may be used or disclosed and how you can get access to it. Please read carefully.
With your consent: Protected Health Information (PHI) can be used or disclosed for treatment, payment, and healthcare operations with your consent.
- Use refers to activities within my office for applying and conducting business.
- Disclosure refers to activities outside of the office for managing your care and conducting business.
- Treatment refers to provision, coordination and management of your mental health care.
- Payment refers to reimbursement for your care.
- Health Care Operations are activities related to the performance and operation of office business.
Authorization for Release of Information: Outside of treatment, payment, and health care operations your written permission will be required for the use or disclosure of your PHI. This Authorization adds an extra protection to your PHI, over and above general consent, and will be obtained from you before releasing your PHI.
Without Consent or Authorization: Your PHI may be used or disclosed without your consent or authorization in the following circumstances:
- Child Abuse: Information that leads to the suspicion of child abuse must be reported. Relevant information from your PHI must be turned over to the local Department of Social Services.
- Adult and Domestic Abuse: Information that leads to the suspicion of abuse of disabled or elderly adults must be reported to the local Department of Social Services.
- Health Oversight: Licensing/Certifying Boards have the power to subpoena PHI, which relates to a legal or ethical inquiry about a clinician’s practice.
- Judicial or Administrative Proceedings: If a judge issues a court order for your PHI record, it must be released to the court. If you are being evaluated for a third party (e.g. disability, fitness for duty, court order), the PHI must be released. Every attempt will be made to notify you in advance if this is the case.
- Serious Threat to the Health or Safety of Yourself or Others.
- Worker’s Compensation: The law requires the release of your relevant PHI to your employer and the NC Industrial Commission, if you file a worker’s compensation claim.
Client Rights: You have the right to:
- Treatment, including access to medical care and habilitation; regardless of age, disability, and/or sex
- Request restrictions on certain uses and disclosures of your PHI although clinician is not required to agree to your request. Clinician will discuss disagreement about your request if you ask.
- Receive confidential information communication by alternative means and at alternative locations (e.g., not have bill sent to your home address).
- Obtain a copy of your treatment plan at anytime. If you wish to obtain an additional or updated copy of your treatment plan you may request a copy during your next normally scheduled appointment or via written communication at anytime at the address below.
- Inspect and obtain a copy of your PHI upon your written request. Your access may be denied under certain circumstances and you may request that the denial be reviewed. Clinician is pleased to discuss the details of the request and denial process with you if you ask. Psychotherapy notes are for clinician’s use only, are separate from your PHI, and are not available to you.
- Request an amendment to your PHI. Your request may be denied by clinician. Clinician will discuss the amendment process with you if you ask.
- Request an accounting of disclosures of your PHI.
Amanda R. Jones, MSW, LCSW
122 St. Mary’s Street
Raleigh, NC 27605
Clinician’s Duties: Clinician is required by law to maintain the privacy of your PHI and to provide you with this PRIVACY NOTICE of privacy practices. Current patients will be notified by mail in the event there are revisions to the privacy policies and practices.
Right to contact Disability Rights of NC:
You have the right to consult with an individual advocate. If you believe that your privacy rights have been violated or if you are dissatisfied with our privacy policies or procedures, you may file a complaint either with us or with the federal government. We will not take any action against you or change our treatment of you in any way if you file a complaint.
You can contact the Disability Rights of NC 1-800-821-6922) the statewide agency designated under Federal and State law to protect and advocate the rights of persons with disabilities.
If you don’t like our services, you have the right to file a grievance or complaint directly with the clinician. Please contact Amanda R. Jones, MSW, LCSW on the 24-hour number (919) 645-8477.
To file a written complaint, you may bring your complaint to Amanda R. Jones, MSW, LCSW or you may mail it to the following address:
Amanda R. Jones, MSW, LCSW
122 St. Mary’s Street
Raleigh, NC 27605
To file a complaint with the federal government, you may send your complaint to the following address:
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If you file a complaint, we will not take any action against you or change our treatment of you in any way.
This PRIVACY NOTICE goes into effect on 10/15/2015. Your signature on the attached Consent Agreement indicates that you have read and understood the content of this PRIVACY NOTICE.