We Care About Your Privacy

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. The terms of the Privacy Notice apply to the medical practice of Cedar Oaks Clinic PLLC and is effective May 10, 2021.

In the course of evaluating and treating you, I may obtain Protected Health Information (PHI) from you and from other medical and non-medical informants. With your signed Treatment Consent, I may use and disclose the minimum necessary information for purposes of Treatment, Payment, and Healthcare Operations (TPO). Examples of treatment purposes include sharing information with other professionals, relatives, or friends involved in your care, arranging a hospitalization, placing diagnoses on order forms for laboratory or other tests, telephoning prescriptions or providing information to third parties necessary to obtain insurance coverage for prescription drugs, etc. Examples of payment purposes include submitting information electronically or on paper to a third-party payer such as Blue Cross Blue Shield, to a utilization review professional to have services authorized for payment and to a collection agency. Examples of healthcare operations include quality assurance activities. (We do not disclose patient names to anyone for marketing purposes.) An appointment reminder message may be left on your voicemail or email account.

I am legally required or permitted to release PHI, without your consent or authorization, to the Department of Health and Human Services (HHS), upon its request to state or local agencies in cases of suspected child or elder abuse, domestic violence, certain infectious diseases, injury, death, or other public health purposes; to the Food and Drug Administration in case of adverse events or product recalls; in legal proceedings, if your mental condition becomes an issue. If I believe you pose an imminent danger to yourself or others, I must disclose PHI to those necessary to prevent injury to yourself or another. Other uses and disclosures of PHI will be made only with your written authorization, which you may revoke in writing at any time except to the extent that action has been taken in reliance thereon.

You have the right to receive confidential communication of PHI. You have the right to inspect and receive copies of PHI. (Exceptions include separate psychotherapy notes, if any information compiled for civil criminal or administrative proceedings; information obtained from a non-healthcare professional under a promise of confidentiality where access would reveal the source, if release is likely to endanger the life or physical safety of, or cause substantial harm to you or another person, etc.) You agree to accept a summary of the PHI instead of copies if I believe this is appropriate and you may be charged for copying or for preparation of a summary. You have the right to request, in writing and including supporting reasons, that your PHI be amended. I may accept or deny the request, in which case, you may submit a written statement of disagreement to which I may prepare a rebuttal. You have the right to receive an accounting of disclosures of your PHI made by me after April 14, 2003. You have the right to request restrictions on certain uses and disclosures of PHI. However, I am not required to agree to your requested restrictions and may refuse to treat you if I do not agree with such a request.

I am required by law to maintain the privacy of PHI and to provide you with notice of my legal duties and privacy practices with respect to PHI. I am required to abide by the terms of the notice currently in effect. I may review the terms of this Privacy Notice and make new provisions effective for all the PHI maintained. The revised Notice will be posted in my reception area and new copies will be made available upon request.

You may complain in writing to myself and to the Secretary of Health and Human Services in Washington D.C. if you believe your privacy rights have been violated. You will not be retaliated against for filing a complaint. The contact person is me at the phone number and address below.

I have read and understand the policy and I have received a copy of the form.

Cedar Oaks Clinic PLLC – Psychiatry and Mental Wellness
1748 Heritage Center Drive, Suite 101
Wake Forest, NC, 27587
[email protected]