KATHLEEN LONG, PH.D.
NOTICE FORM
Notice of Policies and Practices to Protect the Privacy of Your Health Information


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 CAREFULLY.

I. Uses and Disclosures for Treatment, Payment, and Health Care Operations:
 
Kathleen Long, Ph.D. may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:

  •  "PHI" refers to information in your health record that could identify you.
  •  "Treatment, Payment and Health Care Operations"

Treatment is when Kathleen Long, Ph.D. provides, coordinates or manages your health care and   other services related to your health care. An example of treatment would be when Kathleen Long, Ph.D. consults with another health care provider, such as your family physician or another psychologist.

Payment is when Kathleen Long, Ph.D. obtains reimbursement for your health care. Examples of payment are when Kathleen Long, Ph.D. discloses your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.

Health Care Operations are activities that relate to the performance and operation of Dr. Long’s practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination. 

  • "Use" applies only to activities within Dr. Long’s office, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
  •  "Disclosure" applies to activities outside of Dr. Long’s office, such as releasing, transferring, or providing access to information about you to other parties.

II. Uses and Disclosures Requiring Authorization:

Kathleen Long, Ph.D. may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An "authorization" is written permission above and beyond thegeneral consent that permits only specific disclosures. In those instances when information is requested for purposes outside of treatment, payment and health care operations, Kathleen Long, Ph.D. will obtain an authorization from you before releasing this information. Kathleen Long, Ph.D. will also need to obtain an authorization before releasing your psychotherapy notes. " Psychotherapy notes" are notes that have been made about your conversations during a private, group, joint, or family counseling session, which Kathleen Long, Ph.D. has kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI.

You may revoke all such authorizations (for PHI or psychotherapy notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) Dr. Long has relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.

III. Uses and Disclosures with Neither Consent nor Authorization:

Kathleen Long, Ph.D. may use or disclose PHI without your consent or authorization in the following circumstances:

  • Child Abuse: If you provide information that leads to suspicion of child abuse, neglect, or death due to maltreatment, Kathleen Long, Ph.D. 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, Kathleen Long, Ph.D. must do so.
  • Adult and Domestic Abuse: If information you share during assessment or treatment services gives reasonable cause to believe that a disabled adult is in need of protective services, Kathleen Long, Ph.D. must report this to the Director of Social Services.
  • Health Oversight: The North Carolina Psychology Board has the power, when necessary, to subpoena relevant records should your evaluator or therapist 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 have been provided to you and/or the records thereof, such information is privileged under state law, and Kathleen Long, Ph.D. 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: Kathleen Long, Ph.D. 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, Kathleen Long, Ph.D. is required by law to provide your mental health information relevant to the claim to your employer and the North Carolina Industrial Commission.
IV. Patient's Rights and Psychologist's Duties:

   Patient's Rights:

  •  Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, Kathleen Long, Ph.D. is not required to agree to a restriction you request.
  • 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 receiving services. Upon your request, Kathleen Long, Ph.D. will send your bills to another address.
  • Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in your mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. Kathleen Long, Ph.D. may deny your access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. On your request, Kathleen Long, Ph.D. will discuss with you the details of the request and denial process.
  • Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. Kathleen Long, Ph.D. may deny your request. On your request, Kathleen Long, Ph.D. will discuss with you the details of the amendment process.
  • Right to an Accounting – 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 request, Kathleen Long, Ph.D. will discuss with you the details of the accounting process.
  • Right to a Paper Copy – You have the right to obtain a paper copy of the notice from Dr. Long upon request, even if you have agreed to receive the notice electronically.

  Mental Health Professionals' Duties:

  •  Kathleen Long, Ph.D. is required by law to maintain the privacy of PHI and to provide you with a notice of its legal duties and privacy practices with respect to PHI.
  • Kathleen Long, Ph.D. reserves the right to change the privacy policies and practices described in this notice. Unless you are notified of such changes, however, Kathleen Long, Ph.D. is required to abide by the terms currently in effect.
  • If Kathleen Long, Ph.D. revises her policies and procedures, she will notify you of these revisions by posting the revised notice in the waiting room and making a copy available upon your request.

V. Complaints:

If you are concerned that Kathleen Long, Ph.D. has violated your privacy rights, or you disagree with a decision made about access to your records, you may contact Dr. Long at 252-636-2286 to discuss your complaint and receive further information. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The person listed above can provide you with the appropriate address upon request.

VI. Effective Date, Restrictions and Changes to Privacy Policy:

This notice is effective as of April 14, 2003. Kathleen Long, Ph.D. reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that she maintains. Kathleen Long, Ph.D. will provide you with a revised notice by posting it in the waiting room and making copies available upon your request.

Kathleen Long, Ph.D.
Licensed Psychologist