Notice of Privacy Practices

THIS NOTICE OF PRIVACY PRACTICES DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This Notice of Privacy Practices (“Notice”) describes how Cognitive Psychiatry of Chapel Hill, PLLC (“CPCH” or “we”, “us”, or “our”) may use and disclose your protected health information for treatment, payment, and healthcare operations, and for other purposes described in this Notice.

1. Our Responsibilities

We are required by law to provide you with notice of our legal duties and privacy practices with respect to protected health information. This Notice describes how we may use and disclose protected health information about you to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

We are required to abide by the terms of this Notice. We reserve the right to change the terms of this Notice, at any time. Any revisions to this Notice will be effective for all protected health information that we maintain at that time. Any revised Notice will be available in our office, on our website, or upon your request by calling our office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.

We are required by law to maintain the privacy of protected health information and to notify you following a breach of your unsecured protected health information.

2. Uses and Disclosures of Protected Health Information

A. Uses and Disclosures for Treatment, Payment, and Health Care Operations.

Your protected health information may be used and disclosed by us for treatment, payment, or health care operations purposes without your authorization. Following are examples of the types of uses and disclosures of your protected health information that we are permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with another health care provider. For example, we may disclose your protected health information to another physician or health care provider who is treating you, such as another physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Payment: Your protected health information will be used and disclosed, as needed, to obtain payment for your health care services provided by us or by another provider. For example, we may provide your protected health information to your health insurance plan so your health insurance plan can undertake certain activities before it approves or pays for the health care services we recommend or provide to you, such as: making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. We may also bill you or your health plan for the services that we provide to you.

Health Care Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of our practice. These activities include, but are not limited to, quality assessment activities, patient safety activities, employee review activities, training employees and medical students, licensing, conducting or arranging medical review, legal services, auditing functions, and other business activities.

Business Associates: We will share your protected health information with third party “business associates” that perform various activities (for example, billing or transcription services) for our practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that requires the business associate to protect the privacy of your protected health information.

Treatment Alternatives: We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. You may contact our Privacy Officer to request that these materials not be sent to you.

Disclosures to You: We may disclose protected health information to you. We may use your protected health information to contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

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Disclosures to Your Personal Representative: We may disclose protected health information about you to your personal representative. Your personal representative is generally someone who has the authority under state law to act on your behalf in making decisions related to your health care. If you are deceased, your personal representative would be the person who has the authority under state law to act on behalf of you or your estate.

Incidental Disclosures: Disclosures that are incidental to permitted or required disclosures may take place and are permitted by HIPAA. For example, someone may overhear a discussion of your treatment in our office.

B. Other Permitted and Required Uses and Disclosures That May Be Made Without Your Authorization or Opportunity to Agree or Object.

We may use or disclose your protected health information in the following situations without your authorization and without providing you the opportunity to agree or object. These situations include:

Required By Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law. This includes disclosures of your protected health information to the Secretary of the U.S. Department of Health and Human Services when requested by the Secretary to review our compliance with HIPAA.

Public Health: We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. For example, a disclosure may be made for the purpose of preventing or controlling disease, injury or disability.

Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

Health Oversight: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.

Abuse or Neglect: We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.

Food and Drug Administration: We may disclose your protected health information to a person or company required by the Food and Drug Administration for the purpose of quality, safety, or effectiveness of FDA-regulated products or activities including, to report adverse events, product defects or problems, biologic product deviations, to track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.

Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), or in certain conditions in response to a subpoena, discovery request or other lawful process.

Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes of a suspect, fugitive, material witness, or missing person, (3) information about a suspected crime victim if, under certain limited circumstances, we are unable to obtain a person’s agreement because of incapacity or emergency, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of our practice, and (6) medical emergency (not on our practice’s premises) and it is likely that a crime has occurred.

Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.

Research: We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.

Limited Data Set: We may use or disclose protected health information about you in a limited data set for the purposes of research, public health, or health care operations (in a limited data set, certain identifying information about you is removed). The person receiving the information must enter into an agreement to use appropriate safeguards to protect the information.

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To Avert a Serious Threat to Health or Safety: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.

Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities to assure the proper execution of the military mission; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.

Workers’ Compensation: We may disclose your protected health information as authorized to comply with workers’ compensation laws and other similar legally-established programs.

Inmates: We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you.

C. Other Permitted and Required Uses and Disclosures That Require Providing You the Opportunity to Agree or Object:

We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information for these purposes. If you are not present or able to agree or object to the use or disclosure of the protected health information, then we may, using our professional judgment, determine whether the disclosure is in your best interest.

Others Involved in Your Health Care or Payment for your Care: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.

If you are a minor receiving treatment for pregnancy, venereal disease, alcohol or substance abuse, or emotional disturbances, we will comply with state law confidentiality requirements (which in certain cases may require the minor’s authorization to release protected health information, including to the minor’s parent or guardian).

D. Uses and Disclosures of Protected Health Information that Require Your Written Authorization:

Psychotherapy Notes: Psychotherapy notes are notes regarding your counseling sessions that are kept separate from your medical record. We will not use or disclose psychotherapy notes about you without your written authorization, except the author of the notes may use the notes for the purpose of treating you, and we may use or disclose the psychotherapy notes for our own training purposes, to defend ourselves in a legal action or other proceeding brought by you, for certain health oversight activities regarding the author of the notes, to the coroner or medical examiner, for certain research purposes, or as otherwise permitted or required by HIPAA.

Other Uses and Disclosures: Other uses and disclosures of your protected health information not described in this Notice, including disclosures for certain marketing purposes and disclosures made in exchange for payment on behalf of the recipient of such information, will be made only with your written authorization. You may revoke this authorization in writing at any time. If you revoke your authorization, we will no longer use or disclose your protected health information for the reasons covered by your written authorization. Please understand that we are unable to take back any disclosures already made with your authorization.

HIV/AIDS, Mental Health, Developmental Disabilities, and Substance Abuse: In some situations, federal and state laws may provide special protections for certain types of protected health information. Before we share this type of protected health information, we may require written permission from you. Examples of protected health information that are sometimes specially protected include protected health information involving HIV/AIDS, mental health, developmental disabilities, or substance abuse. We may refuse to share these special types of protected health information or we may contact you if written permission is needed to disclose the information.

For Alcohol and Drug Abuse Patients: The confidentiality of alcohol and drug abuse patient records maintained by us is protected by federal law and regulations. Generally, CPCH may not say to a person outside of CPCH that a patient attends the program, or disclose any information identifying a patient as an alcohol or drug abuser unless (1) the patient consents in writing; (2) the disclosure

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is allowed by a court order; or (3) the disclosure is made to a medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation.

Federal law and regulations do not protect any information about (1) a crime committed by a patient either at CPCH or against any other person who works for the program or about any threat to commit such a crime; or (2) suspected child abuse or neglect from being reported under state law to appropriate state or local authorities.

Violation of the federal law and regulations by CPCH is a crime. Suspected violations may be reported to appropriate authorities in accordance with federal regulations. See 42 U.S.C. 290dd-3 and 42 U.S.C. 290ee-3 for Federal laws and 42 CFR part 2 for more information.

3. Your Rights

Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.

Right to Inspect and Copy: You have the right to inspect and obtain a paper or electronic copy of certain protected health information that we maintain about you for so long as we maintain the protected health information. This includes your medical and billing records and other records that we use for making decisions about you. Under federal law, however, this does not include the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and certain laboratory results that are subject to, or fall within certain exemptions to, the Clinical Laboratory Improvements Amendments of 1988.

We may deny your request to inspect and copy protected health information in certain limited circumstances. If we deny your request, we will inform you of this decision in writing, including a description of the reason we denied your request and any rights you have to ask us to review our decision.

To request access to your medical records, you must submit a written request to the Privacy Officer. We may charge you a reasonable cost-based fee for a copy of your records. Please contact our Privacy Officer if you have questions about access to your medical record.

Right to Request Restrictions: You have the right to request restrictions on the use or disclosure of your protected health information that we may use for the purposes of treatment, payment or health care operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care.

We are not required to agree to restrictions that you may request, other than restrictions on disclosures to your health plan or insurance company for services that you paid for in full out of pocket. If we agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless (a) it is needed to provide emergency treatment, (b) the disclosure is required by law, or (c) the disclosure is made to the Secretary of the U.S. Department of Health and Human Services to determine our compliance with HIPAA.

Please submit any request for restrictions in writing to the Privacy Officer. Your request must state the specific restriction requested (including the protected health information and the uses and disclosures to be restricted) and to whom you want the restriction to apply.

Right to Receive Confidential Communications: You have the right to request to receive confidential communications from us by alternative means or at an alternative location. For example, you may request that we contact you at work rather than at home.

You must submit your request to the Privacy Officer in writing. You must specify how you would like us to contact you (for example, by providing an alternative address, phone number, or other method of contact). We will accommodate reasonable requests. We may condition this accommodation by asking you for information as to how payment will be handled. We will not request an explanation from you as to the basis for the request.

Right to Amend: You may have the right to have us amend your protected health information. This means you may request an amendment of protected health information about you in a designated record set for so long as we maintain this information. You must submit your request for amendment in writing to the Privacy Officer. Your request must include the reason for your request. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, we will tell you the reason for our decision in writing. You then have the right to file a statement of disagreement with us, and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Officer if you have questions about amending your medical record.

Right to an Accounting of Disclosures: You have the right to receive an accounting of certain disclosures of your protected health information that we have made for up to six years prior to the date of your request. This right excludes certain disclosures for treatment, payment or health care operations purposes. It also excludes disclosures we may have made to you, we have made to others if you expressly authorized us to make the disclosure, to family members or friends involved in your care, or for certain

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notification purposes (including without limitation for national security or intelligence, to law enforcement or correctional facilities), incidental disclosures, and as part of a limited data set that does not identify you. The right to receive this information is subject to certain exceptions, restrictions and limitations.

Please submit all requests for an accounting of disclosures to the Privacy Officer in writing. We will provide one accounting a year for free, but we will charge a reasonable, cost-based fee if you ask for another one within a twelve month period.

Right to Receive a Paper Copy of this Notice: You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically. Please contact the Privacy Officer to request a paper copy of this notice.

4. Complaints

You may complain to us or to the Secretary of the U.S. Department of Health and Human Services if you believe your privacy rights have been violated by us. We will not retaliate against you for filing a complaint.

You may file a complaint with us by contacting our Privacy Officer at:

James Pleasants, Jr. (Jimmy)

919-636-5240

office@cognitive-psychiatry.com

1200 Environ Way Chapel Hill NC 27517

Please contact our Privacy Officer if you have any other questions about our privacy practices. Effective Date: 10/9/14

To download and acknowledge these practices, please click here.