W. Ellen Fox, PhD, LMFT
How might MarriageMatters, PLLC, use your Health Information, Treatment, Payment, and Healthcare Operations? I may use or disclose your health information to a physician or other healthcare provider providing treatment for you. I may use or disclose your health information for healthcare operations, such as quality assessment and improvement activities, to review the competence or qualifications of healthcare professionals, for evaluation of practitioner and provider performance, for conducting training programs, accreditation, certification, licensing, or credentialing activities. I may use and disclose your health information to obtain payment for services I provide to you.
Is my authorization required to release my health information?
Your given/written authorization to use your health information or to disclose it to anyone for any purpose is required, unless in an emergency or as legally ordered (described below.) If you give me authorization, you may revoke it in writing at any time. Your revocation will not affect any use of disclosures permitted by your authorization while it was in effect. Without written authorization, I will not disclose health information unless otherwise described in this notice.
When might you disclose my health information to a family member or health representative?
I may use or disclose health information to notify, or assist in the notification of a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, I will provide you with an opportunity to object to such use or disclosures. In the event of your incapacity or emergency circumstances, I will disclose health information based on a determination using my professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. I will also use my professional judgment and my experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up health information.
Will you use my health information for marketing?
I will not use your health information for marketing communication.
Are you required by law to release my health information?
I may use or disclose your health information when I am required by law to do so, or if a court of law orders your records.
What about if you suspect I am at risk for abuse, neglect, being the victim of a crime, suicide, or homicide? I may disclose your health information to appropriate authorities if I reasonably believe that you are a possible victim of abuse, neglect or domestic violence or the possible victim of other crimes. I may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.
Will you send me appointment reminders?
I may disclose your health information to provide you with appointment reminders (such as voicemail messages or texts) as requested.
Will I have access to my client file?
In most cases, you have the right to inspect and copy your medical and billing records. You must submit your request in writing. You have the right to request your records in electronic form. If you request a copy of information, I may charge a fee for the costs and time of copying. I may deny your request to inspect and copy information in some circumstances.
How will I know that you have released my health information to anyone?
You have the right to receive an accounting of disclosures of your health information and may submit a written request for this account.
May I place restrictions on what information you release about me?
You have the right to request that I place additional restrictions on our use or disclosure of your health information. I am not required to agree to these additional restrictions, but if I do, I will abide by our agreement (except in an emergency). If paying out of pocket for services, you may restrict the release of information to your insurance provider.
Do I have other options about how the place or method we communicate- such as telehealth?
You have the right to request in writing that I communicate with you about your health information by alternative means or to alternative locations. You must provide satisfactory explanation of how payments will be handled under the alternative means or locations.
May I request that you change information in my file?
You have the right to request in writing that I amend your health information. Your request must explain the reason for amendment. I may deny your request under certain circumstances.
May I have a copy of this notice?
You have a right to a paper copy of this notice and may request this at any time. If you received this notice electronically, you have the right to receive it in writing.
What will happen if my health information privacy is ever breached?
You will be notified in the case of any breach of unsecured health information.
What if I have a complaint about services you rendered to me?
If you want more information about my privacy practices or if you have any questions, please contact me. If you are concerned that I may have violated your privacy rights or you disagree with a decision I made about your health information, you may file a complaint in writing using the contact information at the end of this Notice. You may also submit a written complaint to the U.S. Department of Health and Human Services. I support your right to privacy and will not retaliate if you file a complaint, or to my licensure board, the North Carolina Marriage and Family Therapy Board at https://www.ncbmft.org/resources-and-information/consumer-resources/file-a-complaint.
W. Ellen Fox, PhD, LMFT
Address: 100 B Stadium Oaks Drive, Clemmons, NC 27012
This Notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
What is your legal duty regarding my health information?
I am required by applicable federal and state law to this Notice about privacy practices, my legal duties, and your rights concerning your health information. I must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect January 1, 2020 and will remain in effect until I replace it.
Will the terms of my privacy regarding my health information remain in place?
I reserve the right to change my privacy practices and the terms of the Notice at any time, provided such changes are permitted by applicable law. I reserve the right to make the changes in my privacy practices and the new terms of my Notice effective for all health information that we maintain, including health information I created or received before I made the changes. Before I make a significant change in my privacy practices, I will change this Notice and make a new Notice available upon request.