Confidentiality Policy

It is the policy of Sapia Psychological Associates Inc., to protect the confidentiality and privacy of the clients who receive services from us.
Sapia Psychological Associates Inc.observes and abides by all state and federal laws regarding the privacy and confidentiality of records. In accordance with the Health Insurance Portability & Accountability Act of 1996 (HIPAA) Sapia Psychological Associates Inc. endorses the following procedure to protect the confidential information of clients.

Procedure:

1. Definitions:
   Client: A client for the purposes of this policy is anyone who has/is receiving services from Sapia Psychological Associates Inc.
   Privacy: Privacy is the client’s legal right to have information about them protected from review by other individuals without their permission.
   Confidentiality: Confidentiality is the process in which Sapia Psychological Associates Inc. protects the privacy of clients receiving services.
   Staff: Any office personnel who work for Sapia Psychological Associates Inc..
   Disclosure: Disclosure is the act of releasing information from one individual to another. Within this policy it refers to the releasing of private client information to another party.
   Amendment: An amendment is a request for a change to be made in information kept on file.
2. Sapia Psychological Associates Inc. maintains full responsibility for all aspects of client privacy as the Privacy Representative for the clinical practice.  Any concerns regarding confidentiality or requests of information amendments should be made to Sapia Psychological Associates Inc., or may be made to the state licensing board maintained by the North Carolina Psychology Board.  Requests for releasing of information will be processed by Sapia Psychological Associates Inc.
3. All staff and all clients receiving services from Sapia Psychological Associates Inc. will review the Confidentiality and Privacy Policy.
1. There will be a confidentiality agreement signed by staff kept on file. This agreement will indicate the commitment of staff to abide by the policy as well as state and federal laws on confidentiality. Clients may request to review these agreements.
2. New clients will receive a copy of the policy, which will also be reviewed with them by Sapia Psychological Associates Inc.  Their signature will be kept on file indicating that they have received and reviewed the policy.
3. Authorization for Release of Information will be:
   a. Written in specific language to indicate exactly what type of information is to be disclosed and to what person or entity the disclosure will be made.
4. There will be an expiration date on all Authorizations for Release of Information, which will not exceed 12 months from the date of the signature on the release.
5. Protected information requiring the Authorization for Release of Information shall include but not be limited to photographs, name and identifying information, social security number, diagnosis, session dates and contact dates, progress notes and assessments. Any information regarding a client who is receiving services or who has received services in the past from Sapia Psychological Associates Inc. will be considered private information to be protected.
6. An Authorized Signature will be the person who has legal rights to sign for the client according to the law. For an adult it will be the person who has the legal authority to act as guardian for the individual whose information is to be disclosed.  For children it will be the legal parent or guardian who provides the authority to release information. Children over the age of 12 will also sign, as required by mental health code, before information about that child is released.
7. The least information required will be released in the effort to comply with requests to release information.  Assessment and intake reports will be released only if specifically asked for and approved by the authorized signature on the Authorization to Release of Information.
8. For releases received by outside entities Sapia Psychological Associates Inc. will contact the client for the purpose of obtaining an official release and to discuss any concerns regarding the type of information to be disclosed. The therapist reserves the right to raise concerns with their client regarding whether or not requested information should be disclosed.  North Carolina state law permits the therapist to withhold information if the therapist believes such release would be detrimental to the well-being of the client.

4. Disclosure Contact information will be kept in the file each time information is disclosed to a third party.  The list of Disclosure Contacts may be reviewed by clients upon request.
5. Clients have the right to review their records in the presence of the treating provider with an appointment.
6. Client Information Amendment Requests may be made by clients when they object to information in their file or would like to have information within their file modified.  Clients shall make this request in writing.  Clients may submit this request to Sapia Psychological Associates Inc..
7. Confidential Communications with clients will be conducted as the client prefers. Client demographic information such as address and phone numbers will be gathered for the client file. However, the client will be asked upon admission to outpatient services where they would like confidential communications in writing and by phone to be made. Sapia Psychological Associates Inc. will ask for any restrictions in the type of information to be left in messages or communicated in any form upon intake. Once the client has received the policy and acknowledged they have received the policy in writing it is the client’s responsibility to inform Sapia Psychological Associates Inc. of any changes they request in how confidential communication is handled after the first session. If a change is requested, Sapia Psychological Associates Inc. will immediately make the change in the file indicating the person who made the request and the date of the requested change.
8. Sapia Psychological Associates Inc. will safeguard client records within the computer by:

1. Assuring that if the computer is not in use and is unattended, the computer will be shut down and the staff person logged out.  Once logged out a password will be needed to access the computer
2. All client records stored on removable electronic storage media will be locked in a secure area when not in use.

9. Sapia Psychological Associates Inc. will safeguard client records on paper by assuring that unattended files are locked in secure cabinets at all times.
10. Client files may be destroyed in a manner that protects confidentiality either by shredding or burning of files.  Client files are maintained as required by the North Carolina Mental Health code and HIPAA.

LIMITS TO CONFIDENTIALITY AND MANDATED REPORTING

While most information shared with a mental health professional is private and confidential, licensed psychologists are required to disclose information to other parties under certain circumstances:

1. All licensed psychologists are required by law to report any suspected instances of child abuse or neglect to the department of social services in your county.  Making a report does not necessarily mean that the psychologist believes abuse or neglect occurred, only that a reasonable person might suspect it did.
2. Similarly, the law requires that mental health professionals contact authorities in the event that elder abuse is discovered.  This means that an adult age 60 or over who cannot make a call themselves is suspected of being abused or neglected.
3. If a psychologist believes you are at risk of attempting suicide, the courts have mandated that the psychologist notify any parties necessary to ensure your safety, for example, police, emergency services, family members.
4. If a psychologist believes you are at risk of harming or killing someone else, the courts have held that the psychologist must warn the intended victim and/or others who can prevent the assault from occurring.
5. Psychologists are permitted by law to provide limited information to collection agencies in the event that you would refuse to pay a lawful bill for services.
6. If a psychologist is ordered by a court to testify about you against your wishes, the psychologist will make efforts to avoid testifying, e.g., asserting your right to confidential communications, but may not always be able to do so.
7. If you are referred for services by the court or by your employer they may require that certain information be released back to them.  Clarify what is required before sharing personal information with a psychologist.

A psychologist may legally and ethically seek professional consultation with another professional about your case.  In such a situation, the consultant will be legally required to treat that information as confidential.