Notice of Privacy Practices
Effective Date: 12/19/2025

THIS NOTICE DESCRIBES HOW PSYCHOTHERAPY AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Your health record contains personal information about you and your health. State and Federal law protects the confidentiality of this information. Protected Health Information (PHI) is information about you, including demographic information, that may identify you and that relates to your past, present, or future physical and mental health, or condition, and related health care services. If you suspect a violation of these legal protections, you may file a report to the appropriate authorities in accordance with Federal and State regulations.

The practice is required by law to maintain the privacy of your PHI and to provide you with notice of my legal duties and privacy practices with respect to your PHI. This Notice of Privacy Practices describes how the practice may use and disclose your PHI in accordance with all applicable law. It also describes your rights regarding how you may gain access to and control your PHI. The practice is required to abide by the terms of this Notice of Privacy Practices. The practice reserves the right to change the terms of the Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that I maintain at that time. The practice will make available a revised Notice of Privacy Practices by sending you an electronic copy, sending a copy to you in the mail upon your request, or providing one to you in person.

USE AND DISCLOSURE OF YOUR PHI

For Treatment: Use of medical and clinical information about you to provide treatment services.

For Payment: Use and disclosure of medical information about you to receive payment for the treatment services provided to you.

For Healthcare Operations: Use and disclosure of your protected PHI for certain purposes in connection with the operation of the professional practice, including supervision and consultation.

Without Your Authorization: State and Federal law also permits the provider to disclose information about you without your authorization in a limited number of situations, such as with a court order.

With Authorization: Provider must obtain written authorization from you for other uses and disclosures of your PHI.  You may revoke such authorizations in writing in accordance with 45 CFR. 164.508(b)(5).

Incidental Use and Disclosure: Provider is not required to eliminate every risk of incidental use or disclosure of your PHI.  Specifically, a use or disclosure of your PHI that occurs as a result of, or incident to an otherwise permitted use or disclosure is permitted as long as the provider has adopted reasonable safeguards to protect your PHI, and the information being shared was limited to the minimum necessary. 

EXAMPLES OF USE AND DISCLOSURE OF YOUR PHI

These examples are not meant to be a complete list of all possible disclosures, rather, they are illustrative of the types of uses and disclosures that may be made.

Treatment: Your PHI may be used and disclosed by the provider for the purpose of providing, coordinating, or managing your health care treatment and any related services. This may include coordination or management of your health care with a third party, consultation or supervision activities with other health care providers, or referral to another provider for health care services.

Payment: The practice may use your PHI to obtain payment for your health care services. This may include providing information to a third party payor, or, in the case of unpaid fees, submitting your name and amount owed to a collection agency.

Healthcare Operations: The provider may use or disclose your PHI in order to support the business activities of the provider’s professional practice including; disclosures to others for health care education, or to provide planning, quality assurance, peer review, or administrative, legal, financial, or actuarial services to assist in the delivery of health care, provided there is a written contract with the business that prohibits it from re-disclosing your PHI and requires it to safeguard the privacy of your PHI.

OTHER USES AND DISCLOSURES THAT DO NOT REQUIRE YOUR AUTHORIZATION

Required by Law: The provider may use or disclose your PHI to the extent that the use or disclosure is required by law, made in compliance with the law, and limited to the relevant requirements of the law. Examples of this type of disclosure include healthcare licensure related reports, public health reports, and law enforcement reports. Under the law, the provider must make certain disclosures of your PHI to you upon your request. In addition, the provider must make disclosures to the US Secretary of the Department of Health and Human Services for the purpose of investigating or determining compliance with the requirements of privacy rules.

Health Oversight: The provider may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies and organizations that provide financial assistance to the program (such as third-party payors) and peer review organizations performing utilization and quality control.  If the practice discloses PHI to a health oversight agency, there will be an agreement in place that requires the agency to safeguard the privacy of your information.

Abuse or Neglect: The provider may disclose your PHI to a state or local agency that is authorized by law to receive reports of abuse or neglect.  However, the information disclosed is limited to only that information which is necessary to make the required mandated report.

Deceased Clients: The provider may disclose PHI regarding deceased clients for the purpose of determining the cause of death, in connection with laws requiring the collection of death or other vital statistics, or permitting inquiry into the cause of death.

Research: The practice may disclose PHI to researchers if (a) an Institutional Review Board reviews and approves the research and a waiver to the authorization requirement; (b) the researchers establish protocols to ensure the privacy of your PHI; and (c) the researchers agree to maintain the security of your PHI in accordance with applicable laws and regulations.

Criminal Activity or Threats to Personal Safety: The provider may disclose your PHI to law enforcement officials if the provider reasonably believes that the disclosure will avoid or minimize an imminent threat to the health or safety of yourself or any third party.

Compulsory Process: The provider may be required to disclose your PHI if a court of competent jurisdiction issues an appropriate order, and if the rule of privilege has been determined not to apply. The provider may be required to disclose your PHI if notified in writing at least fourteen days in advance of a subpoena or other legal demand, no protective order has been obtained, and a competent judicial officer has determined that the rule of privilege does not apply.

Essential Government Functions: The provider may be required to disclose your PHI for certain essential government functions.  Such functions include: assuring proper execution of a military mission, conducting intelligence and national security activities that are authorized by law, providing protective services to the President, making medical suitability determinations for U.S. State Department employees, protecting the health and safety of inmates or employees in a correctional institution, and determining eligibility for or conducting enrollment in certain government benefit programs.

Law Enforcement Purpose:  The provider may be authorized to disclose your PHI to law enforcement officials for law enforcement purposes under the following six circumstances, and subject to specified conditions: (1) as required by law (including court orders, court-ordered warrants, subpoenas) and administrative requests; (2) to identify or locate a suspect, fugitive, material witness, or missing person; (3) in response to a law enforcement official’s request for information about a victim or suspected victim of a crime; (4) to alert law enforcement of a person’s death, if the provider’s suspects that criminal activity caused the death; (5) when the provider believes that protected health information is evidence of a crime that occurred on the practice premises; and (6) in a medical emergency not occurring on practice premises, when necessary to inform law enforcement about the commission and nature of a crime, the location of the crime or crime victims, and the perpetrator of the crime. 

Incapacity or Death of Provider: If the provider becomes incapacitated or dies, PHI may be disclosed to a designated professional executor or records custodian for the limited purpose of managing, transferring, maintaining, or disposing of clinical records and facilitating continuity of care. Any disclosure will be limited to the minimum necessary information and will remain subject to HIPAA and applicable North Carolina confidentiality laws.

USES AND DISCLOSURES OF PHI WITH YOUR WRITTEN AUTHORIZATION

Other uses and disclosures of your PHI will be made only with your written authorization. The practice will not make any other uses or disclosures of your psychotherapy notes. The practice will not use or disclosure your PHI for marketing proposes, and not sell your PHI without your authorization. You may revoke your authorization in writing at any time. Such revocation of authorization will not be effective for actions the provider may have taken in reliance on your authorization of the use or disclosure.

Your Rights Regarding Your PHI

You have the following rights regarding PHI that the practice maintains about you. Any requests with respect to these rights must be in writing. A brief description of how you may exercise these rights is included.

Right of Access to Inspect and Copy: You may inspect and obtain a copy of your PHI that is contained in a designated record set for as long as the practice maintains the record. A "designated record set" contains medical and billing records and any other records that the practice uses for making decisions about you. Your request must be in writing. The practice may charge you a reasonable cost-based fee for the copying and transmitting of your PHI. The provider can deny you access to your PHI in certain circumstances.  In some of those cases, you will have a right of recourse to the denial of access. Please contact the provider if you have questions about access to your medical record.

Right to Amend: You may request, in writing, that the provider amend your PHI that has been included in a designated record set. In certain cases, the provider may deny your request for an amendment. If the provider denies your request for amendment, you have the right to file a statement of disagreement with the provider. The provider may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

Right to an Accounting of Disclosures: You may request an accounting of disclosures made for treatment purposes or made as a result of your authorization, for a period of up to six years, excluding disclosures made to you. The practice may charge you a reasonable fee if you request more than one accounting in any 12-month period.  Please contact the practice if you have questions about accounting of disclosures.

Right to Request Restrictions: You have the right to ask the practice not to use or disclose any part of your PHI for treatment, payment or health care operations or to family members involved in your care. Your request for restrictions must be in writing, and the provider is not required to agree to such restrictions. Please contact the provider if you would like to request restrictions on the disclosure of your PHI. You also have the right to restrict certain disclosures of your PHI to your health plan if you pay out of pocket in full for the health care provided to you.

Right to Request Confidential Communication: You have the right to request to receive confidential communications from the provider by alternative means or at an alternative location. The provider will accommodate reasonable written requests. The provider may also condition this accommodation by asking you for information regarding how payment will be handled or specification of an alternative address or other method of contact. Please contact the practice if you would like to make this request.

Right to a Copy of this Notice: You have the right to obtain a copy of this notice from the practice. Any questions you have about the contents of this document should be directed to the provider.

Right to Opt Out: You have the right to choose not to receive fundraising communications. However, the practice will not contact you for fundraising purposes.

Right to Notice of Breach: You have the right to be notified of any breach of your unsecured PHI. 

COMPLAINTS

You have the right to complain if you feel the provider has violated your rights. The practice will not retaliate against you for filing a complaint. You may either file a complaint directly with us by contacting Samantha Smith, LCMHC.  All complaints must be submitted in writing; or with the Office for Civil Rights at the US Department of Health and Human Services. Send a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201 call 1-877-696-6775; or visit www.hhs.gov/ocr/privacy/hipaa/complaints/. 

ACKNOWLEGEMENT OF RECEIPT

Acknowledgment of Receipt By signing this document, I acknowledge that I have received a copy of Dig Space Counseling Service’s Notice of Privacy Practices and that I read and understood it. I understand that:

• I have certain rights to privacy regarding my PHI

• The Dig Space Counseling Services can and will use my PHI for purposes of my treatment, payment, and health care operations

• The Notice of Privacy Practices explains in more detail how The Dig Space Counseling Services may use and share my PHI for other purposes

• I have the rights regarding my PHI listed in the Notice of Privacy Practices

• The Dig Space Counseling Services has the right to change the Notice of Privacy Practices from time to time and I can obtain a current copy of the Notice by the practice.