By law we are required to insure that your PHI is kept private.  The PHI constitutes information
created or noted by your therapist that can be used to identify you.  It contains data about your
past, present, or future health or condition, the provision of health care services to you, or the
payment for such health care.  We are required to provide you with this Notice about our privacy
procedures. This Notice must explain when, why, and how we would use and/or disclose your PHI.
Use of PHI means when we share, apply, utilize, examine, or analyze information within the
practice; PHI is disclosed when we release, transfer, give, or otherwise reveal it to a third party
outside the practice. With some exceptions, we may not use or disclose more of your PHI than is
necessary to accomplish the purpose for which the use or disclosure is made; however, we are
always legally required to follow the privacy practices described in this Notice.
Please note that we reserve the right to change the terms of this Notice and privacy policies at any
time.  Any changes will apply to PHI already on file with The Therapy Place.  Before making any
important changes to policies, if this Notice changes  the new version will immediately be posted in
the office and on the website (not applicable).  You may also request a copy of this Notice at
anytime, or you can view a copy of it in my office or on the website, which is located at (The-

Your PHI will be used and disclosed for many different reasons.  Some of the uses or disclosures
will require your prior written authorization; others, however, will not. Below you will find the
different categories of my uses and disclosures, with some examples.

A. Uses and Disclosures Related to Treatment, Payment, or Health Care Operations Do Not
Require Your Prior Written Consent. Your PHI will be used and disclosed without your consent for
the following reasons:
For treatment.
 Your PHI may be disclosed to physicians, psychiatrists, psychologists, and other licensed             
 health care providers who provide you with health care services or are otherwise involved in       
 your care. Example: If a psychiatrist is treating you, We may disclose your PHI to her/him in
  order to  coordinate your care.

For health care operations.
  We may disclose your PHI to facilitate the efficient and correct operation of the practice.
  Examples:  Quality control - We might use your PHI in the evaluation of the quality of health
  care  services that you have received or to evaluate the performance of the health care
  professionals who provided you with these services.  We may also provide your PHI to      
  attorneys, accountants, consultants, and others to make sure that I am in compliance with
  applicable laws.

To obtain payment for treatment.
 We may use and disclose your PHI to bill and collect payment for the treatment and services
  provided. Example:  We may send your PHI to your insurance company or health plan in order
  receive payment for the health care services that have been provided.  We could also         
 provide your PHI to business associates, such as billing companies, claims processing
  companies, and others that process health care claims for this office.

Other disclosures.   
 Examples:  Your consent isn't required if you need emergency treatment provided that we
  attempt to get your consent after treatment is rendered. In the event that we try to get your
  consent but you are unable to communicate with me (for example, if you are unconscious or in
  severe pain) but I think that you would consent to such treatment if you could, I may disclose
  your PHI.

Certain Other Uses and Disclosures Do Not Require Your Consent. We may use
and/or disclose your PHI without your consent or authorization for the following
1.        When disclosure is required by federal, state, or local law; judicial, board, or administrative
  proceedings; or, law enforcement. Example: We may make a disclosure to the appropriate
  officials when a law requires me to report information to government agencies, law
  enforcement personnel and/or in an administrative proceeding.

2.        If disclosure is compelled by a party to a proceeding before a court of an administrative
  agency pursuant to its lawful authority.

3.        If disclosure is required by a search warrant lawfully issued to a governmental law
  enforcement agency.

4.        If disclosure is compelled by the patient or the patient’s representative pursuant to North
  Carolina Health and Safety Codes or to corresponding federal statutes of regulations, such as
  the Privacy Rule that requires this Notice.

5.        To avoid harm. We may provide PHI to law enforcement personnel or persons able to
  prevent or mitigate a serious threat to the health or safety of a person or the public.

6.        If disclosure is compelled or permitted by the fact that you are in such mental or emotional
  condition as to be dangerous to yourself or the person or property of others, and if determined
  that disclosure is necessary to prevent the threatened danger.

7.        If disclosure is mandated by the North Carolina Child Abuse and Neglect Reporting law.  For
  example, if we have a reasonable suspicion of child abuse or neglect. If disclosure is mandated
  by the North Carolina Elder/Dependent Adult Abuse Reporting law.  For example, if we have a
  reasonable suspicion of elder abuse or dependent adult abuse.

8.        If disclosure is compelled or permitted by the fact that you tell me of a serious/imminent
  threat of physical violence by you against a reasonably identifiable victim or victims.

9.        For public health activities.  Example: In the event of your death, if a disclosure is permitted
  or compelled, we may need to give the county coroner information about you.

10.        For health oversight activities.  Example: We may be required to provide information to
  assist the government in the course of an investigation or inspection of a health care
  organization or provider.

11.        For specific government functions.  Examples: We may disclose PHI of military personnel
  and veterans under certain circumstances. Also, we may disclose PHI in the interests of
  national security, such as protecting the President of the United States or assisting with
  intelligence operations.

12.        For research purposes. In certain circumstances, we may provide PHI in order to conduct
  medical research.

13.        For Workers' Compensation purposes.  We may provide PHI in order to comply with
  Workers' Compensation laws.

14.        Appointment reminders and health related benefits or services. Examples: We may use PHI
  to provide appointment reminders.  We may use PHI to give you information about alternative
  treatment options, or other health care services or benefits we offer.

15.        If an arbitrator or arbitration panel compels disclosure, when arbitration is lawfully
  requested by either party, pursuant to subpoena duces tectum (e.g., a subpoena for mental
  health records) or any other provision authorizing disclosure in a proceeding before an
  arbitrator or arbitration panel.

16.        We are permitted to contact you, without your prior authorization, to provide appointment
         reminders or information about alternative or other heath-related benefits and services
          that may be of interest to you.

17.        If disclosure is required or permitted to a health oversight agency for oversight activities
  authorized by law.  Example: When compelled by U.S. Secretary of Health and Human
  Services to investigate or assess my compliance with HIPAA regulations.

18.        If disclosure is otherwise specifically required by law.

Certain Uses and Disclosures Require You to Have the Opportunity to Object.

Disclosures to family, friends, or others.  We may provide your PHI to a family member, friend, or
other individual who you indicate is involved in your care or responsible for the payment for your
health care, unless you object in whole or in part.  Retroactive consent may be obtained in
emergency situations.

Other Uses and Disclosures Require Your Prior Written Authorization.

In any other situation not described in Sections IIIA, IIIB, and IIIC above, We will request your
written authorization before using or disclosing any of your PHI. Even if you have signed an
authorization to disclose your PHI, you may later revoke that authorization, in writing, to stop any
future uses and disclosures (assuming that we have not taken any action subsequent to the original
authorization) of your PHI by The Therapy Place or Your Provider.


These are your rights with respect to your PHI:

A. The Right to See and Get Copies of Your PHI.
  In general, you have the right to see your PHI that is in my possession, or to get copies of it;       
 however, you must request it in writing.  If we do not have your PHI, but know who does, we
  will advise you how you can get it. You will receive a response from your provider within 30
  days of my receiving your written request. Under certain circumstances, we may feel we must
  deny your request, but if we do, we will give you, in writing, the reasons for the denial.   We will
  also explain your right to have my denial reviewed.
 If you ask for copies of your PHI, we will charge you not more than $.25 per page. We may see  
  fit to provide you with a summary or explanation of the PHI, but only if you agree to it, as well  
  as to the cost, in advance.

B. The Right to Request Limits on Uses and Disclosures of Your PHI.
 You have the right to ask that we limit how we use and disclose your PHI. While we will
  consider your request, we are not legally bound to agree. If we do agree to your request, we will
  put those limits in writing and abide by them except in emergency situations. You do not have   
  the right to limit the uses and disclosures that we are legally required or permitted to make.

C. The Right to Choose How We Send Your PHI to You.
  It is your right to ask that your PHI be sent to you at an alternate address (for example,
  sending information to your work address rather than your home address) or by an alternate
  method (for example, via email instead of by regular mail).  We are obliged to agree to your
  request providing that we can give you the PHI, in the format you requested, without undue

D. The Right to Get a List of the Disclosures I Have Made.
 You are entitled to a list of disclosures of your PHI that have been made. The list will not
  include uses or disclosures to which you have already consented, i.e., those for treatment,         
 payment, or health care operations, sent directly to you, or to your family; neither will the list
  include disclosures made for national security purposes, to corrections or law enforcement
  personnel, or disclosures made before April 15, 2003.  After April 15, 2003, disclosure records
  will be held for six years.

 We will respond to your request for an accounting of disclosures within 60 days of receiving
  your request. The list given to you will include disclosures made in the previous six years (the    
 first six year period being 2003-2009) unless you indicate a shorter period. The list will include
  the date of the disclosure, to whom PHI was disclosed (including their address, if known), a        
  description of the information disclosed, and the reason for the disclosure. We will provide the
  list to you at no cost, unless you make more than one request in the same year, in which case
  we will charge you a reasonable sum based on a set fee for each additional request.

E. The Right to Amend Your PHI.
 If you believe that there is some error in your PHI or that important information has been
  omitted, it is your right to request that it be corrected. Your request and the reason for the
  request must be made in writing. You will receive a response within 60 days of receipt of your
  request. We may deny your request, in writing, if we find that: the PHI is (a) correct and
  complete, (b) forbidden to be disclosed, (c) not part of the records, or (d) written by someone
  other than the provider. Our denial must be in writing and must state the reasons for the denial.
  It must also explain your right to file a written statement objecting to the denial. If you do not
  file a written objection, you still have the right to ask that your request and my denial be
  attached to any future disclosures of your PHI. If you request is  approved, we will make the
  change(s) to your PHI. Additionally, we will inform you that the changes have been made, and
  will advise all others who need to know about the change(s) to your PHI.

F. The Right to Get This Notice by Email You have the right to get this notice by email. You have
  the right to request a paper copy of it, as well.


If, in your opinion, we may have violated your privacy rights, or if you object to a decision we
made about access to your PHI, you are entitled to file a complaint with the person listed in Section
VI below. You may also send a written complaint to the Secretary of the Department of Health and
Human Services at 200 Independence Avenue S.W. Washington, D.C. 20201. If you file a
complaint about our privacy practices, we will take no retaliatory action against you.

If you have any questions about this notice or any complaints about our privacy practices, or
would like to know how to file a complaint with the Secretary of the Department of Health and
Human Services, please contact: The Therapy Place, Gretchen Laporta LCSW  P.O. Box 5011
Monroe NC 28111

This notice went into effect on May 1, 2009.

                                            Acknowledgement of Receipt

This form, when completed by you, acknowledges that you agree to the Notice of Privacy Practices
and the Psychological Provider Patient Services Agreement.

I ____________________________________ acknowledge that I have received the
following forms and agree to abide by their guidelines:
    _______ Notice of Privacy Practices

    _______ Psychological Provider Patient Services Contracts (2)

In so doing, I specifically agree to the Protected Health Information for the purposes of treatment,
payment and health care operations, as defined in the Notice of Privacy Practices.

________________________           _____________       
Signature of Client/Guardian                        Date

_______________________             _____________              
Client Name Printed                                        Date of Birth