Notice of Privacy Practices
This notice describes how psychological information about you may be used and disclosed and how you can get access to this information. Please review it carefully. If you have any questions about the information contained in this Notice, please contact: Tiffany Wagner, M.S., LMFT (919)412-7321.
Mental health information, including psychological or psychiatric treatment records, are subject to special protections under North Carolina law. Tiffany Wagner, M.S., LMFT will generally only release such records or information with your written authorization or with an appropriate court order. You may revoke all such authorizations at any time, to the extent that we have taken any action based on this consent.
I may use and disclose your mental health information without your consent to improve and conduct the mental health care operations of Tiffany Wagner, M.S., LMFT. For example, we may use your mental health information within the organization in order to evaluate the quality of health care services that you have received, or to evaluate the performance of the professionals who provided mental health care services to you. We may call you by name in the waiting and service areas.
There are some occasions in which I may use or disclose your psychological treatment information without your consent:
- Child Abuse: If you give me information which leads me to suspect child abuse, neglect, or death due to maltreatment, I 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, I must do so.
- Adult and Domestic Abuse: If information you give me gives me reasonable cause to believe that a disabled adult is in need of protective services, I must report this to the Director of Social Services.
- Health Oversight: North Carolina professional licensing boards have the power, when necessary, to subpoena relevant records should a psychologist or counselor in the organization 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 I have provided you and/or the records thereof, such information is privileged under the state law, and I 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: I may disclose your confidential information to protect you or others from a serious threat of harm by you.
- Workers’s Compensation: If you file a worker’s compensation claim, I am required by law to provide your mental health information relevant to the claim to your employer and the North Carolina Industrial Commission.
You have the following rights regarding your mental health care information:
- Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, I am 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 mental health care information by alternative means and at alternative locations.
- Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of mental health care information in my treatment records used to make decisions about you for as long as the mental health care information is maintained in the record. I may deny your access to this information under certain circumstances, but in some cases, you may have this decision reviewed. On your request, a professional will discuss with you the details of the request and denial process.
- Right to Amend – You have the right to request an amendment of mental health care information for as long as that information is maintained in the record. I may deny your request. On your request, a staff member will discuss with you the details of the amendment process.
- Right to Accounting – You generally have the right to receive an accounting of disclosures of your mental health care information for which you have neither provided consent nor authorization (as described in Section III of this Notice). On your request, a professional 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.
Tiffany Wagner, M.S., LMFT has the following responsibilities for your mental health care information:
- I am required by law to maintain the privacy of mental health care information and to provide you with a notice of our legal duties and privacy practices with respect to your mental health care information.
- I reserve the right to change the privacy policies and practices described in this Notice. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect.
- If I revise my policies and procedures, I will provide you with a written copy of my revised policies upon your next visit.
If you have questions about this Notice, disagree with a decision I make about access to your records, believe that your privacy rights have been violated and wish to file a complaint with my office or have other concerns about your privacy rights, you may contact Tiffany Wagner M.S., LMFT (919)412-7321 602 East Academy Street Suite 205 Fuquay Varina, NC 27526. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The person listed above can provide you with the appropriate address upon request. You have specific rights under the Privacy Rule. Tiffany Wagner, M.S., LMFT will not retaliate against you for exercising your right to file a complaint.