Policies & Practices to Protect the Privacy of your Health Information
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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  

HOLLY B. SAVOY, 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: 

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• “PHI” refers to information in your health record that could identify you.

• "Treatment, Payment and Health Care Operations” 

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

• Payment is when HOLLY B. SAVOY, PH.D. obtains reimbursement for your healthcare. Examples of payment are when HOLLY B. SAVOY, 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 our 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 our practice group, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you. 

• “Disclosure” applies to activities outside of our practice group, such as releasing, transferring, or providing access to information about you to other parties. 

II. Uses and Disclosures Requiring Authorization 

HOLLY B. SAVOY, 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 the general consent that permits only specific disclosures. In those instances when HOLLY B. SAVOY, PH.D. is asked for information for purposes outside of treatment, payment and health care operations, HOLLY B. SAVOY, PH.D. will obtain an authorization from you before releasing this information. HOLLY B. SAVOY, PH.D. will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes HOLLY B. SAVOY, PH.D. has made about our conversations during a private, group, joint, or family counseling session, which HOLLY B. SAVOY, 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 (of PHI or psychotherapy notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) HOLLY B. SAVOY, PH.D. 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 

HOLLY B. SAVOY, PH.D. may use or disclose PHI without your consent or authorization in the following circumstances: 

·  Child Abuse: If you give us information which leads us to suspect child abuse, neglect, or death due to maltreatment, HOLLY B. SAVOY, 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, HOLLY B. SAVOY, PH.D. must do so. 

·  Adult and Domestic Abuse: If information you give us gives us reasonable cause to believe that a disabled adult is in need of protective services, HOLLY B. SAVOY, 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 HOLLY B. SAVOY, PH.D. 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 HOLLY B. SAVOY, PH.D. has provided you and/or the records thereof, such information is privileged under state law, and HOLLY B. SAVOY, 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: HOLLY B. SAVOY, 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, HOLLY B. SAVOY, 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. Client's Rights and Psychologist's Duties 

Client’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, HOLLY B. SAVOY, 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 seeing us. Upon your request, HOLLY B. SAVOY, 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 our mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. HOLLY B. SAVOY, PH.D. may deny your access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. On your request, HOLLY B. SAVOY, 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. HOLLY B. SAVOY, PH.D. may deny your request. On your request, HOLLY B. SAVOY, 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, HOLLY B. SAVOY, 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 us upon request, even if you have agreed to receive the notice electronically. 

Psychologist’s Duties: 

·  HOLLY B. SAVOY, PH.D. is required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI. 

·  HOLLY B. SAVOY, PH.D. reserves the right to change the privacy policies and practices described in this notice. Unless HOLLY B. SAVOY, PH.D. notifies you of such changes, however, HOLLY B. SAVOY, PH.D. is required to abide by the terms currently in effect. 

·  If HOLLY B. SAVOY, PH.D. revises our policies and procedures, HOLLY B. SAVOY, PH.D. will notify you in writing by mail within 30 days. 

V. Questions and Complaints 

If you have questions about this notice, disagree with a decision HOLLY B. SAVOY, PH.D. make about access to your records, or have other concerns about your privacy rights, you may contact Dr. Savoy at 704-362-4041. If you believe that your privacy rights have been violated and wish to file a complaint with our office, you may send your written complaint to my office at: HOLLY B. SAVOY, PH.D., 4425 Randolph Road, Suite 411,  Charlotte, NC   28211. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. You have specific rights under the Privacy Rule. HOLLY B. SAVOY, PH.D. will not retaliate against you for exercising your right to file a complaint. 

VI. Effective Date, Restrictions and Changes to Privacy Policy 

This notice will go into effect on October 1, 2008.  HOLLY B. SAVOY, PH.D. reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that HOLLY B. SAVOY, PH.D. maintains. HOLLY B. SAVOY, PH.D. will provide you with a revised notice by publishing the changes, posting these changes at HOLLY B. SAVOY, PH.D. office and distributing the revised notice to all active clients.

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