Rights to Treatment: As a client of Agape Psychological Consortium, you are entitled to competent, compassionate, and ethical treatment services. Such services include: access to medical care and habilitation - regardless of age and degree of MH/IDD/SA disability.

We, at Agape Psychological Consortium, do not disclose personal information unless we are allowed, required by law, or given written authorization by the legally responsible person(s) to do so. When allowed, or mandated, we may use and disclose personal information in the following ways:

Treatment: We may use and disclose personal health information to plan, coordinate and provide services to clients.

Payment: We may use and disclose personal health information to obtain payment for health-care services that we have provided to the client and/or guardian.

Health-care operations: We may use or disclose personal health information for our health-care operations (i.e., risk assessment and quality assurance functions

Authorized release of information: The legally responsible person(s) of a minor child and client, who has reached the age of 18, can authorize the release of personal health information. This authorization can be revoked at any time; however, the revocation will not impact the release of information that was disclosed prior to receipt of said revocation of authorization for release of records. Questions about written its release will be answered by the Director.

Professional Colleagues: There are some services that are provided through contracts with business associates. In such situations, we may disclose personal health information to our business associates so they can perform the requested services. As noted, we require business associates to adhere to the same required standards to safeguard personal health information as described in this notice and in accordance with all applicable law.

Family Members: We may use, or disclose your child’s personal health information to inform a family member, personal representative or another person who is responsible for his/her care. If circumstances do not permit us to obtain consent for the disclosure of personal health information (i.e., medical emergency), then we may disclose personal health information to a family member or friend to the extent necessary to help with the immediate care or payment for the care. We will only do so if we determine that the disclosure is in your child’s best interest. In all such cases, we will only disclose the health information that is directly relevant to that person’s involvement with your child’s health-care.

Required by Law: We may use or disclose personal health information to the extent that we are required by law to do so. Such uses or disclosure will be made in compliance with the applicable law governing said uses and disclosures.

Law Enforcement: We may disclose personal health information for a law enforcement purpose to law enforcement officials in compliance with and as limited by applicable law.

Public Health and Safety: We may disclose personal health information if we believe that disclosure is necessary to avert a serious and imminent threat to the health and safety of yourself, your child, or the health and safety of others. We may disclose personal health information for public health activities to public health authorities authorized by law to collect or receive information for the purpose of controlling disease, injury or disability.

Judicial and Administrative Proceedings: We may disclose personal health information in the course of any judicial administrative hearing in response to an order of a court or administrative tribunal, or in response to a subpoena, discovery request or other lawful processes where we receive satisfactory assurance that appropriate precautions have been taken for the privacy of said information. In all cases, we will take reasonable steps to protect the confidentiality of you and/or your child’s health information.

Research: We may use or disclose your child’s personal health information for purposes of research by taking necessary precautions not to disclose personal identification information regarding you and/or your child or his/her personal health information. Only the minimal necessary information shall be used and only that allowed by law.

Victims of Abuse, Neglect or Domestic Violence: We may disclose personal health information about an individual whom we reasonably believe to be a victim of abuse, neglect or domestic violence to a government authority (i.e., social service or protective service agency) authorized by law to receive reports of child abuse, neglect or domestic violence. Any such disclosures will be made in accordance with and limited to the requirements of the law.

Right to Refuse Treatment: Because we are here to serve you (i.e., provide therapeutic and diagnostic services), you have the right to refuse treatment at any time – without penalty, cost, or retaliation. If needed or requested, we will assist you in obtaining services from other treatment providers or agencies.

Your (child’s) rights regarding the use and disclosure of personal health information (HIPAA)

You have the following rights regarding your (or your child’s) personal health information:

Right to Receive a Copy of This Notice: You may request a copy of this notice at any time; one will be provided to you

Right to Receive Further Information: You have the right to contact the Director, or Office Manager, at our agency if you: (a) want additional information about our privacy practices, your child’s privacy rights, or to disagree about a decision we made about your child’s personal health information, or (b) if you believe your child’s privacy rights have been violated. The Director or Office Manager will provide you with the information needed to file a complaint.

Right to Inspect and/or Receive a Copy of Your Protected Health Information: Upon written request, you have the right to access and/or obtain a copy of your/your minor child’s health information maintained by us. We may deny your request to inspect and copy in certain limited circumstances if, based on our clinical judgment, it may perpetuate/create a safety risk to yourself or others.

Right to Amend Your Health Information: You have the right to request that we amend/change the records that we keep about you/your child if you believe that the information is incomplete or incorrect.

Right to Request Additional Restrictions on Disclosures of Protected Health Information: You have the right to request that we place additional restrictions on how we use or disclose your/your child’s protected health information. We must obtain such a request, in writing addressed to the Director, any requests for additional restrictions. Please note that we are not required to agree with your request.

Right to Request Confidentiality in Certain Communications: You have the right to request how we communicate with you in order to preserve our privacy areas. For example, you may request that we call you only at a specified number, or by mail at a specific address or postal box. Your request must be made in writing to the Director or Office Manager and must specify how or where we are to contact you.

Right to File a Complaint: If you believe that your/your child’s privacy rights have been violated, you have the right to file a complaint with the Director. Please file the claim as soon as possible in writing, providing as much detail as you can about the suspected violation. You also have the right to file a written complaint with the Office of Civil Rights of the United States Department of Health and Human Services. Upon request, the Office Manager will provide you the information needed to file a complaint. Under no circumstances will we retaliate against you or your child for filing a complaint with us or with the Office of Civil Rights.

Right to Withdraw from Treatment: If you are no longer in need of, or wish to discontinue, services at Agape Psychological Consortium, then inform the Office Manager/therapist of your desire. We will honor your desire and, if needed or requested, assist you in obtaining other services. Treatment can be withdrawn at any time and, if you so choose, without explanation.

Uses of Disclosures Not Covered: Uses of disclosures of your/your child’s personal health information not covered by this notice or the laws that apply to us may only be made with your written authorization. You may revoke such authorization in writing at any time and we will no longer disclose health information about you for the reason stated in your written authorization. Disclosures made in reliance on the authorization prior to the revocation are not affected by the revocation.

Client Grievance:

We are concerned with any problems you may experience with our program. To address the problems, we need to know about them. Therefore, we have set up a Grievance Procedure, which we request that you use. If you have a problem with this program, or if you believe that any of your rights have been violated, you may personally inform, or mail your complaint to, the Director at: Agape Psychological Consortium, PLLC 4160 Piedmont Pkwy, Suite 207 Greensboro, North Carolina 27410 (336) 855-4649

If you are not satisfied with the Director’s response to your complaint, you can file the or with the Disability Rights NC at 1-919 856-2195 (TTY: 888-268-5535) or email: info@disabilityrightsnc.org.