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Privacy Policy

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

Insight Professional Counseling Services, PLLC (the “Practice”) is committed to protecting your privacy. The Practice is required by federal law to maintain the privacy of Protected Health Information (“PHI”), which is information that identifies or could be used to identify you. The Practice is required to provide you with this Notice of Privacy Practices (this “Notice”), which explains the Practice's legal duties and privacy practices and your rights regarding PHI that we collect and maintain.


YOUR RIGHTS
Your rights regarding PHI are explained below. To exercise these rights, please submit a written request to the Practice at the address noted below.

To inspect and copy PHI:
  • You can ask for an electronic or paper copy of PHI. The Practice may charge you a reasonable fee.
  • The Practice may deny your request if it believes the disclosure will endanger your life or another person's life. You may have a right to have this decision reviewed.

To amend PHI: 
  • You can ask to correct PHI you believe is incorrect or incomplete. This practice requires you to make your request in writing and provide a reason for the request.
  • The Practice may deny your request. The Practice will send a written explanation for the denial and allow you to submit a written statement of disagreement.

To request confidential communications:
  • You can ask the Practice to contact you in a specific way. The Practice will say “yes” to all reasonable requests.

To limit what is used or shared:
  • You can ask the Practice not to use or share PHI for treatment, payment, or business operations. The Practice is not required to agree if it would affect your care.
  • If you pay for a service or health care item out-of-pocket in full, you can ask the Practice not to share PHI with your health insurer.
  • You can ask for the Practice not to share your PHI with family members or friends by stating the specific restriction requested and to whom you want the restriction to apply.

To obtain a list of those with whom your PHI has been shared: 
  • You can ask for a list, called an accounting, of the times your health information has been shared. You can receive one accounting every 12 months at no charge, but you may be charged a reasonable fee if you ask for one more frequently.

To receive a copy of this Notice:
  • You can ask for a paper copy of this Notice, even if you agreed to receive the Notice electronically.

To choose someone to act for you:
  • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights.

To file a complaint if you feel your rights are violated.
You can file a complaint by contacting the Practice using the following information:
Insight Professional Counseling Services, PLLC
1205 S Main Street
Officer: Joanna Warren
336-350-7605

You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. You may also file complaint with Secretary of US Department of Health and Human Services. The Practice nor therapist will not retaliate against you for filing a complaint.

To file a complaint with your therapist licensure board, please see the information below: 
  • Joanna Warren, LMFT- LMFT Licensure Board, PO Box 37669, Raleigh NC 27627. 919-469-8081
  • Cari Sun, LCMHC-LCMHC licensure Board address is PO Box 77819, Greensboro, NC 27417. 336-217-6007
  • Tiffany Hall, LCAS, LCMHC-LCMHC licensure Board address is PO Box 77819, Greensboro, NC 27417. 336-217-6007
  • Alisha Miller-Glasgow, LCMHC-LCMHC licensure Board address is PO Box 77819, Greensboro, NC 27417. 336-217-6007
  • Michelle Lester, LCSWA-NCSWCLB Licensure Board address is P.O. Box 1043 Asheboro, NC 27204.336-625-1679
  • Kersten Perry, LCMHCA-LCMHC licensure Board address is PO Box 77819, Greensboro, NC 27417. 336-217-6007
  • Emily Fogleman Basirico- LCMHCA-LCMHC licensure Board address is PO Box 77819, Greensboro, NC 27417. 336-217-6007
  • Amanda Miller, LCMHC-LCMHC Licensure Board Address is PO Box 77819, Greensboro, NC 27417. 336-217-6007
  • Jennifer Simms LCMHCA-LCMHC Licensure Board Address is PO Box 77819, Greensboro, NC 27417. 336-217-6007
  • Lindsay Ballard, MA, LMFTA Licensure Board, PO Box 37669, Raleigh NC 27627. 919-469-8081
  • Molly Kerns, LCMHCA-LCMHC Licensure Board Address is PO Box 77819, Greensboro, NC 27417, 336-217-6007
  • Aaron Hawkins, LCMHCA-LCMHC Licensure Board Address is PO Box 77819, Greensboro, NC 27417. 336-217-6007
  • Kiana Carter, LCSWA -NCSWCLB Licensure Board Address is P.O. Box 1043, Asheboro, NC 27204. 336-625-1679
  • Katie Chrisco, LCMHCA-LCMHC Licensure Board Address is PO Box 77819, Greensboro, NC 27417. 336-217-6007
  • Sydney Wray, LCMHCA-LCMHC Licensure Board Address is PO Box 77819, Greensboro, NC 27417. 336-217-6007

To opt out of receiving communications - the Practice may contact you for important communication efforts, but you can ask not to be contacted again.


Routine Uses and Disclosures of PHI
The Practice is permitted under federal law to use and disclose PHI, without your written authorization, for certain routine uses and disclosures, such as those made for treatment, payment, and the operation of our business. Business operation may include interns and admission coordinators having access to our EDI program for scheduling purposes, information needed for audits and sending medical records, directors of clinical care and owner assuring clinical best practice while utilizing mandated internal company confidentiality for our profession. We may use or disclose PHI for the purposes outside of treatment, payment, and health care operations when your appropriate authorization is attained. An authorization is written permission above and beyond general consent that permits only specific disclosures. I will also need to obtain an authorization before releasing your psychotherapy notes. Psychotherapy notes are notes that I have made about the conversation during a private, group, joint, or family counseling session, which I have kept separate from your medical records. The Practice typically uses or shares your health information in the following ways:

To treat you:
  • The Practice can use and share PHI with other professionals who are treating you.
  • Example: Your primary care doctor asks about your mental health treatment.

To run the health care operations:
  • The Practice can use and share PHI to run the business, improve your care, and contact you.
  • Example: The Practice uses PHI to send you appointment reminders if you choose.

To bill for your services:
  • The Practice can use and share PHI to bill and get payment from health plans or other entities.
  • Example: The Practice gives PHI to your health insurance plan so it will pay for your services. Also, the practice uses an EDI program, Therapynotes. We have a BAA agreement with our EDI program assuring you that it is HIPAA compliant, and our practice has a professional medical billing company, Medical Billing Professionals.

I may use or disclose PHI without your consent or authorization in the following circumstances:
  • Child, elder, disabled adult and domestic abuse: If information you give me leads me to a reasonable suspicion of abuse or neglect, then I must turn report such information to the Department of Social Services.
  • Health Oversight: The NC Board of LMFT, The LCSW Board, LCAS board, and LCMHC board has the power, when necessary, to subpoena relevant records should I be the focus of a board inquiry.
  • Judicial or Administrative Proceedings: If you are involved in a court proceeding, and a request is made for information about the professional serves that I provided you and/or records thereof, such as information is privileged under state law, and I must not release this information without your written authorization, or a court order from a judge. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advanced if this is the case.
  • Serious Threat to health and safety: I may disclose your confidential information to protect you and others from a serious threat of harm by you.
  • Worker’s compensation: If you file a worker’s compensation claim, I am required by law to provide your mental health information relevant to the claim to your employer and the NC industrial commission.

Counselor’s Duties:
  • I am required by law to maintain the privacy of PHI and to provide you will 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, I am required to abide by the terms currently in effect.
  • If I revise my policies and procedures, I will provide you with a copy of the revisions at your next session.


Uses and Disclosures of PHI That May Be Made Without Your Authorization or Opportunity to Object

The Practice may use or disclose PHI without your authorization or an opportunity for you to object, including:

To help with public health and safety issues
  • Public health: To prevent the spread of disease, assist in product recalls, and report adverse reactions to medication.
  • Required by the Secretary of Health and Human Services: We may be required to disclose your PHI to the Secretary of Health and Human Services to investigate or determine our compliance with the requirements of the final rule on Standards for Privacy of Individually Identifiable Health Information.
  • Health oversight: For audits, investigations, and inspections by government agencies that oversee the health care system, government benefit programs, other government regulatory programs, and civil rights laws.
  • Serious threat to health or safety: To prevent a serious and imminent threat.
  • Abuse or Neglect: To report abuse, neglect, or domestic violence.

To comply with law, law enforcement, or other government requests
  • Required by law: If required by federal, state or local law.
  • Judicial and administrative proceedings: To respond to a court order, subpoena by judge, or discovery request.
  • Law enforcement: For law locate and identify you or disclose information about a victim of a crime.
  • Specialized Government Functions: For military or national security concerns, including intelligence, protective services for heads of state, or your security clearance.
  • National security and intelligence activities: For intelligence, counterintelligence, protection of the President, other authorized persons or foreign heads of state, for purpose of determining your own security clearance and other national security activities authorized by law.
  • Workers' Compensation: To comply with workers' compensation laws or support claims.

To comply with other requests
  • Coroners and Funeral Directors: To perform their legally authorized duties.
  • Organ Donation: For organ donation or transplantation.
  • Research: For research that has been approved by an institutional review board.
  • Inmates: The Practice created or received your PHI in the course of providing care.
  • Business Associates: To organizations that perform functions, activities or services on our behalf.

Uses and Disclosures of PHI That May Be Made With Your Authorization (release of information) or Opportunity to Object

Unless you object, the Practice may disclose PHI if we have release of information:
  • To your family, friends, or others if PHI directly relates to that person's involvement in your care (with release of information).
  • If it is in your best interest because you are unable to state your preference.

Uses and Disclosures of PHI Based Upon Your Written Authorization
The Practice must obtain your written authorization to use and/or disclose PHI for the following purposes:
Marketing, sale of PHI, and psychotherapy notes.

You may revoke your authorization, at any time, by contacting the Practice in writing, using the information above. The Practice will not use or share PHI other than as described in Notice unless you give your permission in writing.

OUR RESPONSIBILITIES
  • The Practice is required by law to maintain the privacy and security of PHI.
  • The Practice is required to abide by the terms of this Notice currently in effect. Where more stringent state or federal law governs PHI, the Practice will abide by the more stringent law.
  • The Practice reserves the right to amend Notice. All changes are applicable to PHI collected and maintained by the Practice. Should the Practice make changes, you may obtain a revised Notice by requesting a copy from the Practice, using the information above, or by viewing a copy on the website .
  • The Practice will inform you if PHI is compromised in a breach.

This facility participates in the North Carolina Health Information Exchange Network, called NC HealthConnex, which is operated by the North Carolina Health Information Exchange Authority (NC HIEA). We will share your protected health information, or PHI, with the NC HIEA and may use NC HealthConnex to access your PHI to assist us in providing health care to you. We are required by law to submit clinical and demographic data pertaining to services paid for with funds from North Carolina programs like Medicaid and State Health Plan. We may also share other patient data with NC HealthConnex not paid for with State funds. If you do not want NC HealthConnex to share your PHI with other health care providers who are participating in NC HealthConnex, you must opt out by submitting a form directly to the NC HIEA. Forms and brochures about NC HealthConnex are available in our offices and online at NCHealthConnex.gov. Again, even if you opt out of NC HealthConnex, we still will submit your PHI if your health care services are funded by State programs. Your patient data may also be exchanged or used by the NC HIEA for public health or research purposes as permitted or required by law. For more information on NC HealthConnex, please visit NCHealthConnex.gov/patients.

This notice revised 8-23-2024
This Notice is effective on 8-23-2024

Good Faith Estimate

Effective January 1, 2022, a ruling went into effect called the "No Surprises Act" which requires practitioners to provider a "Good Faith Estimate" about out-of-network care. The Good Faith Estimate works to show the cost of items and services that are reasonably expected for your health care needs for an item or service, a diagnosis, and a reason for therapy. The estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur and will be provided a new "Good Faith Estimate" should this occur. If this happens, federal law allows you to dispute (appeal) the bill if you and your therapist have not previously talked about the change and you have not been given an updated good faith estimate. 

Under Section 2799B-6 of the Public Health Service Act (PHSA), health care providers and health care facilities are required to inform individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage both orally and in writing of their ability, upon request, or at the time of scheduling health care items and services to receive a "Good Faith Estimate" of expected charges.

Note: The PHSA and GFE does not currently apply to any clients who are using insurance benefits, including "out of network benefits (i.e.., submitting superbills to insurance for reimbursement).

Timeline requirements: Practitioners are required to provide a good faith estimate of expected charges for a scheduled or requested service, including items or services that are reasonably expected to be provided in conjunction with such scheduled or requested item or service.” That estimate must be provided within specified timeframes:
  • If the service is scheduled at least three business days before the appointment date, no later than one business day after the date of scheduling;
  • If the service is scheduled at least 10 business days before the appointment date, no later than three business days after the date of scheduling; or
  • If the uninsured or self-pay patient requests a good faith estimate (without scheduling the service), no later than three business days after the date of the request. A new good faith estimate must be provided, within the specified timeframes if the patient reschedules the requested item or service.

Common Services
  • 90791: Initial therapy intake (not timed)
  • 90837: Ongoing therapy appointments (approx 55 minutes)
  • 90847: Family/Couples appointments (approx 45 minutes)

Common Diagnosis Codes at our Practice
Below are common diagnosis codes at Insight: however, the list is not exhaustive. With that said, diagnosis codes can change based on many factors. Please speak to your therapist with any questions or concerns.
  • Adjustment Disorder (F43.23)
  • Mental Disorder, Not Otherwise Specified (F99)
  • Depression (F32.9)
  • Anxiety (F41.1)
  • Bipolar (F31.9)
  • PTSD/Post Traumatic Stress Disorder (F43.10)

Insight recognizes every client's therapy journey is unique.  How long you need to engage in therapy and how often you attend sessions will be influenced by many factors including: 
  • Your schedule and life circumstances
  • Therapist availability
  • Ongoing life challenges
  • The nature of your specific challenges and how you address them
  • Personal finances

You and your therapist will continually assess the appropriate frequency of therapy and will work together to determine when you have met your goals and are ready for discharge and/or a new "Good Faith Estimate" will be issued should your frequency or needs change.

Where Services Will Be Delivered
Insight is in person and a telehealth practice; as such, all benefits will be quoted based on your needs unless indicated otherwise in the notes section of this document.

Insight location
1205 S Main Street, Burlington NC 27215

Patient Diagnosis
At our practice, we must diagnose all clients for both ethical, legal, and insurance reasons -- as well as required by the "No Surprises Act".

Your Good Faith Estimate diagnosis is:
Primary Diagnosis: Z73.3 - Stress not elsewhere specified 
Secondary Diagnosis: F99 - Mental Health Disorder, Not Otherwise Specified
This diagnosis is only to satisfy the federal requirement for this form. This is not a formal psychological diagnosis. A formal diagnosis occurs after an assessment has been completed. That will take place 1-5 sessions after beginning psychotherapy. If you choose to decline a formal diagnosis, we will not update this GFE. It is within your rights to decline a diagnosis per state and federal guidelines. 

Here are some of the Primary Services or Items Requested/Scheduled
  • Individual Therapy (18+)
  • Individual Therapy (12-17)
  • Couples Therapy
  • Family Therapy

Your Financial Responsibility Summary
For a good faith estimate: the amount you would owe if you were to attend therapy for 52 sessions in a year (weekly, without skipping any weeks for holidays, break, vacation, unplanned events/sickness, etc.). The "Good Faith Estimate" requires practitioners to provide an exact estimate and not a range. Out of an abundance of caution and transparency, we will only quote weekly appointments. Many clients are biweekly. Becasue insurances pay us different amounts and deductibles are different, we are quoting the self pay rate which is similar to most deductibles.

Your annual cost estimate:
Office Practice: Insight Professional Counseling Services
Out of network, deductible, or self pay
Estimate cost is $150.00 for initial visit and $125.00 per session for a total of 52 weeks, taking into considerations holidays, emergencies, vacations, and sick time. Total for 52 weeks : $6,525.00.



Good Faith Estimate Disclaimer
  • This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created. 
  • The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill. 
  • If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill. 
  • You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available. 
  • You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. 
  • There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount. 
  • To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call 800-985-3059. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 800-985-3059. Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.