Privacy Policy
Last updated February 17, 2026
Southpark Psychotherapy PLLC
(980) 999-0501; admin@southparkpsych.com
Notice of Privacy Practices
This document contains important information about federal law, the Health Insurance Portability and Accountability Act (HIPAA), which provides privacy protections and patient rights regarding the use and disclosure of your Protected Health Information (PHI) for treatment, payment, and health care operations.
HIPAA requires me to provide you with a Notice of Privacy Practices (the Notice) regarding the use and disclosure of PHI for treatment, payment, and health care operations. The Notice explains HIPAA and its application to your PHI in greater detail.
The law requires that I obtain your signature acknowledging receipt of this notice. If you have any questions, you have the right and obligation to ask, so I can discuss them further before signing this document. Signing this document will also constitute an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding unless I have taken action in reliance on it.
Limits on Confidentiality
The law protects the privacy of all communication between a patient and a therapist. In most situations, I can release information about your treatment to others only if you sign a written authorization form that meets certain legal requirements under HIPAA. There are situations in which I am permitted or required to disclose information without your consent or authorization. If such a situation arises, I will limit my disclosure to what is necessary.
Except as provided below, federal law protects records that identify a person as having applied for or received services related to substance use disorder, including alcohol or drug use treatment (“SUD”). SUD records cannot be used or disclosed without your written permission (“authorization”) unless federal and state law allows it.
Reasons I may have to release your information without authorization:
1. If you're involved in a court case and are asked for details about your diagnosis and treatment, this information is protected under the psychotherapist-patient privilege law. I cannot share any of it without your written consent, a court order, or a subpoena for which you've been properly notified and do not oppose. If you're involved in or considering legal action, it's advisable to consult an attorney to determine whether a court might require me to disclose this information.
2. If a government agency requests the information for health oversight activities, within its appropriate legal authority, I may be required to provide it to them.
3. If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself.
4. If a patient files a workers' compensation claim, and I am providing necessary treatment related to that claim, I must, upon appropriate request, submit treatment reports to the appropriate parties, including the patient's employer, the insurance carrier, or an authorized qualified rehabilitation provider.
5. I may disclose the minimum necessary health information to my business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. My business associates sign agreements to protect the privacy of your information and are not permitted to use or disclose it except as specified in our contract.
There are some situations in which I am legally obligated to take action that I believe is necessary to protect others from harm. I may have to reveal some information about a patient's treatment:
1. If I know, or have reason to suspect, that a child under 18 has been abused, abandoned, or neglected by a parent, legal custodian, caregiver, or any other person responsible for the child's welfare, the law requires that I file a report with the designated state abuse hotline. Once such a report is filed, I may be required to provide additional information.
2. If I know or have reasonable cause to suspect that a vulnerable adult has been abused, neglected, or exploited, the law requires that I file a report with the designated state abuse hotline. Once such a report is filed, I may be required to provide additional information.
3. If I believe that there is a clear and immediate probability of physical harm to the patient, to other individuals, or to society, I may be required to disclose information to take protective action, including communicating the information to the potential victim, and/or appropriate family member, and/or the police, or to seek hospitalization of the patient.
Clients Rights and Therapist Duties
Use and Disclosure of Protected Health Information:
Federal and State laws allow disclosure of your therapy and other mental health records (excluding SUD treatment) without authorization:
● For Treatment – I use and disclose your health information internally in the course of your treatment. If I wish to provide information outside of our practice for your treatment by another health care provider, I will have you sign an authorization for release of information. Furthermore, an authorization is required for most uses and disclosures of psychotherapy notes.
● For Payment – I may use and disclose your health information to obtain payment for services provided to you as delineated in the Therapy Agreement.
● For Operations – I may use and disclose your health information as part of our internal operations. For example, this could mean reviewing records to ensure quality. I may also use your information to tell you about services, educational activities, and programs that I feel might be of interest to you.
By signing the authorization, you agree that we may disclose SUD care and treatment records, whether provided in this office or by another provider, and that we may use and disclose them for treatment, payment, and operations as described above.
Patient's Rights:
● Right to Treatment – You have the right to ethical treatment without discrimination regarding race, ethnicity, gender identity, sexual orientation, religion, disability status, age, or any other protected category.
● Right to Confidentiality – You have the right to have your health care information protected. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information with your health insurer for payment or operational purposes. I will agree to such unless a law requires us to share that 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 PHI 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 PHI. Records must be requested in writing, and the release of information must be completed. Please submit your request well in advance and allow 2 weeks for the copies to arrive. If I refuse your request for access to your records, you have a right of review, which I will discuss with you upon request.
● Right to Amend – If you believe the information in your records is incorrect and/or missing important information, you can ask us to make certain changes, also known as amending, to your health information. You have to make this request in writing. You must tell us the reasons you want to make these changes, and I will decide if it is, and if I refuse to do so, I will tell you why within 60 days.
● Right to a Copy of This Notice – If you received the paperwork electronically, you have a copy in your email. If you completed this paperwork in the office at your first session, a copy will be provided to you per your request or at any time.
● Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI regarding you. On your request, I will discuss with you the details of the accounting process.
● Right to Choose Someone to Act for You – If someone is your legal guardian, that person can exercise your rights and make choices about your health information; I will make sure the person has this authority and can act for you before I take any action.
● Right to Choose – You have the right to decide not to receive services with me. If you wish, I will provide you with the names of other qualified professionals.
● Right to Terminate – You have the right to terminate therapeutic services with me at any time without any legal or financial obligations other than those already accrued. I ask that you discuss your decision with me in session before terminating or at least contact me by phone to let me know you are terminating services.
● Right to Release Information with Written Consent – With your written consent, any part of your record can be released to any person or agency you designate. Together, we will discuss whether or not I think releasing the information in question to that person or agency might be harmful to you.
Therapist’s Duties:
● I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI. I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect.
Additional Use of AI Technology:
● I may use artificial intelligence (AI) technology to transcribe psychotherapy notes from dictation or recordings to maintain accurate and comprehensive health records. This use is conducted under strict confidentiality and security measures to protect your PHI in compliance with HIPAA regulations. Your psychotherapy notes will not be disclosed to third parties without your written authorization, except as outlined in this notice or as required by law. You may opt out by notifying your therapist of this request in writing and completing the opt-out form.
Complaints:
If you are concerned that I have violated your privacy rights, or you disagree with a decision I made about access to your records, you may contact me, the State of North Carolina Department of Health, or the Secretary of the U.S. Department of Health and Human Services.