NOTICE OF PRIVACY PRACTICES

Fayetteville Family Life Center

A Samaritan Center

114 Highland Avenue

Fayetteville NC  28305

Phone:  (910) 484-0176   Fax:  (910) 484-5781

E-Mail:  fyvllifecntr@earthlink.net

Satellite Offices:

Camp Ground UMC Counseling Services, Camp Ground United Methodist Church

Community Family Counseling Center, First Baptist Church (Moore Street)

Eastside Counseling Center, Lebanon Baptist Church

Our practice follows professional standards and laws to protect your privacy.  Federal laws require us to provide you with a notice of our privacy practices.

This notice describes how your individual identifiable information may be used or disclosed.  Also, this notice describes how you may get access to your individual identifiable information that is maintained by our practice.  Please read this notice and ask us any questions you have on how we keep your information confidential.

Ways We Can Use and Disclose Information WITHOUT Your Permission

Typically, our practice will ask for your written permission or authorization to share or obtain information with others.  However, we may use and disclose information about you without your authorization in the following circumstances:

1.      Treatment:  We may use your information and disclose it to manage or coordinate treatment provided to you.  For example, your therapist may share information with another therapist or your physician to coordinate services.

2.      Payment:  We may use and disclose necessary information about you to obtain payment for our services.  For example, this information could include information that your health insurance plan may require before it approves or pays for treatment services we recommend for you.

3.      Health Care Operations:  We may need to use or disclose information for our practice activities.  Examples of these activities include:

a.      Quality assessment to see how well we are doing in serving individuals, couples, and families.

b.     Clinical supervision of staff to meet state licensure and/or certification requirements.

c.      Education and training of students and other professionals.

d.     Compliance activities to ensure we are properly following policies, procedures, laws, regulations, and professional standards.

We may use or disclose information about you in several other circumstances in which you do not have an opportunity to agree or object.  These situations include:

1.       Required by Law:  We may need to disclose information for judicial or other administrative proceedings.  For example, we may need to disclose information in response to a court order

2.       Abuse or Neglect:  We are required to disclose information if we believe that you or a family member have been a victim of abuse or neglect OR if you or a family member is abusing or neglecting another person.

3.       Danger to Self or Others:  We are required to take steps to prevent your harming yourself or another person.

4.       Law Enforcement:  Law enforcement purposes may include:

a.      Legal processes required by law

b.     Limited information requests for identification and location purposes.

c.      Pertaining to victims of a crime

d.     In the event that a crime occurs on our premises

5.       Public Health:  We may be required to report health related information for public health activities.

6.       Other Circumstances:  Although not typically encountered in our practice, there are other situations when we may disclose information without your written authorization.  Examples of these circumstances include providing information for research, information on inmates or military veterans, and national security activities.

For any reason other that those listed above, we will ask for your written authorization before we use of disclose information about you.  Also, any authorization can be canceled any time in writing.  (If you tell us you are canceling an authorization, we will have you sign a request during the current or next visit.)  If cancelled, we will no longer disclose information that was allowed under that specific authorization.

Your Rights About Your Private Identifiable Information

1.     Request Restrictions:  You may request further restrictions on our uses and disclosures of your information.  We may not be able to agree to all requested restrictions.  Please let us know if you want specific restrictions on your information.

2.      Different Ways to Communicate:  Typically we will communicate by mailing or phoning your residence.  However, you may prefer a different way for us to contact you.  For example, you may ask for us to contact you at a specific address or phone.  Please note that cell phones and e-mail may not offer confidentiality or privacy protections.

3.     Right to See and Copy Information:  You may see and receive copies of your information maintained in your designated record.  We will charge for copying your designated record.  There are situations in which we do not have to comply to your request.  However, we will say in writing if we cannot comply to a request.

4.     Right To Request Amendment of Your Information:  You may request that information about you be amended or changed.  We may deny your request if we did not create the information (it was obtained from another source).  Also, we may deny your request if we believe the information is correct.  Denials will be written and will describe your rights for further review.  If we agree to amend, we will make reasonable efforts to share with any person who may have received your information that it needs amending. 

5.     Listing of Disclosures We Have Made:  You may request a list of certain disclosures of your information for up to the last six (6) years.  This list does not include disclosures made prior to April 14, 2003 (when the Federal Privacy Rule took effect) or disclosures related to your treatment, payment or our practice operations, and those disclosures required by law.   Ask us if you desire a listing of disclosures.

6.     Copy of This Notice:  You may request a copy of this notice at any time.  A copy is available at our practice site(s).

7.     You May File a Complaint About Our Privacy Practice:  If you think we have violated your privacy rights described in this notice, or you want to complain to us about our privacy practices, you can contact the Director or the Privacy Compliance Officer of the Fayetteville Family Life Center.

Also, you may send a written complaint to the Secretary, Department of Health and Human Services

If you send a complaint, we will not take any action against you or change our treatment of you in any way.