Hicks Counseling Services Beverly Hicks, M.Ed. NC: LCMHC, CCS, CADC TX: LMFT, LCDC2301

Mailing: 9650 Strickland Rd. Suite 103-424 Raleigh, NC 27615 Office: 919.904.4257 Fax: 866.594.1848 www.hickscounseling.com

A. PHI is information that is created in the process of assessment and treatment and contains identifying information. It contains data about health conditions, past and present, services provided and payment information.

B. Law requires that this information is protected and that notice is provided as to when, how, and why PHI may be used within the practice and/or disclosed to a third party. Only necessary information is used or disclosed. If these policies change, this Notice shall be updated and posted with changes retroactive to the beginning date of service.

A. Prior Written Consent is Not Needed for Disclosure, Treatment, Payment or Health Care Operations.

1. Treatment. Sharing information with health care providers involved in your care does not require written consent.
2. Healthcare Operations. PHI may be used to facilitate correct operation of the practice (i.e. accounting, legal, and consulting services used by the practice
3. Payment billing and collection services that require use and/or disclosure of PHI, such as billing the insurance company do not require prior consent.
4. Other Disclosures.

• Emergencies.
• Dangerousness. Mental status indicates danger to self, others, or property of others.
• Contact client for appointment reminders, benefits and services of interest.
• Legally required by subpoena or court-order to release PHI.
• Abuse/Neglect suspected of child, disabled or elderly.

B. Prior Written Consent is Required for Use and Disclosure of PHI in Other Circumstances.

1. Family, friends or others-PHI may be shared in coordinating treatment or payment unless you object in part or in whole. You may revoke consent at any time. Emergencies may cover use of information as listed I-A4.
2. Other Situations-In any other situation not described in previous sections, written authorization will be required before using or disclosing your PHI. You may revoke consent at any time and limit information to be released.

A.The Right to See and Get Copies of Your PHI

Must be requested in writing and a response will be given within 30 days of receipt of request. If denied, a written explanation will be provided and can be appealed. There will be a charge of $0.25 per page for printed or copied information. Summaries and Reports requested will also require a charge to be determined upon request.

B. Right To Request Limits on Uses and Disclosures of Your PHI

C. The Right to Get a List of Disclosures Made

Accounting of Disclosures Log is available at no cost (one copy/year), but will not include disclosures for treatment, payment or operations.

D. The Right to Amend Your PHI

If you believe an error or omission of importance exists in your PHI, request made in writing will be addressed within 60 days of receipt. Denials will be made in writing with an explanation as to why and how you can challenge the denial. Your request may be included in the PHI-Denials would occur if the PHI is (a) correct and complete, (b) forbidden to be disclosed, (c) not part of my records, or (d) written by someone else.

E. The Right of a Copy of the Notice

If you feel your rights have been violated or you have an objection, you may file a complaint with me, or you may send a written complaint to the Secretary of the Department of Health and Human Services.

I fully understand and accept/decline the terms of this consent.