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This Notice applies to all the people who provide healthcare services at Wilmington Mental Health in North Carolina. These providers will be referred as “we” in this Notice.


Wilmington Mental Health (“We” or “Us” or “Our”) is required by state and federal law to protect the privacy of your health information that may identify you. This health information includes mental health, developmental disability and/or substance abuse services that are provided to you, payment for those health care services, or other health care operations provided on your behalf.

This agency is required by law to inform you of our legal duties and privacy practices with respect to your health information through this Notice of Privacy Practices. This Notice describes the ways we may share your past, present and future health information, ensuring that we use and/or disclose this information only as we have described in this Notice. We do, however, reserve the right to change our privacy practices and the terms of this Notice, and to make the new Notice provisions effective for all health information we maintain. Any changes to this Notice will be posted in our agency offices and on our agency web site at ( Copies of any revised Notices will be available to you upon request.

If at any time, you have questions or concerns about the information in this Notice or about our agency’s privacy policies, procedures and practices, you may contact our agency Privacy Official at (910) 777-5575.


We understand that health information about you and your health care is personal. We will collect personal information about you and receive such records from others. We will create a record of the care and services you receive from us and store it in a chart or electronic health record. This is your mental health record and is the property of Wilmington Mental Health, but the information in the mental health record belongs to you. We will use these records to provide you with quality care, to obtain payment for services provided to you as allowed by your health plan, and to enable us to comply with certain legal requirements. This notice applies to all the records of your care generated through our work with you, the patient.


For Treatment: Wilmington Mental Health may use your health information, as needed, in order to provide, coordinate or manage your health care and related services. This includes sharing your health information with other health care providers within this agency. For instance, your treatment team (e.g., doctor, nurses, social worker, counselor) may need to review your treatment and discuss plans for your discharge.

We will disclose your health information outside of this agency for treatment purposes only with your consent or when otherwise allowed under state or federal law (e.g., for emergency services; GS 90-109.1). If you request treatment and rehabilitation for drug dependence, your request will be treated as confidential. We will not refer you to another person for treatment and rehabilitation without your consent.

For Payment: The treatment provided to you will be shared with our agency’s billing department so a bill can be prepared for services rendered. We may also share your health information with agency staff who review services provided to you to make certain you have received appropriate care and treatment. We will not disclose your health information outside of this agency for billing purposes (i.e., bill your insurance company) without your consent except in certain situations when we need to determine if you are eligible for benefits, such as contacting your local Department of Social Services to determine if you are currently eligible for treatment.

For Health Care Operations: Wilmington Mental Health may use or disclose your health information in performing a variety of business activities that we call “health care operations”. Some examples of how we may use or disclose your health information for health care operations are:

  • Review the care you receive here and evaluating the performance of your treatment/habilitation team to ensure you have received quality care.
  • Review and evaluate the skills, qualifications and performance of health care providers who are taking care of you.
  • Provide training programs for agency staff, students, and volunteers.
  • Cooperate with outside organizations that review and determine the quality of care that you receive.
  • Allow our agency attorney to use your health information when representing this agency in legal matters.
  • Provide information to professional organizations that evaluate, certify or license health care providers, staff or facilities.
  • Resolve grievances within our agency.
  • Provide information to your internal client advocate who is available to represent your interests upon your request.

Other Circumstances For Which Authorization Is Not Required
Wilmington Mental Health may disclose your health information for those circumstances that have been determined to be so important that your authorization may not be required. Prior to disclosing your health information, we will evaluate each request to ensure that only necessary information will be disclosed. Those circumstances include disclosures that are:

  • For appointment reminders and health related benefits or services. We may use and disclose your PHI to contact you to remind you that you have an appointment with us. We may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that we offer.
  • For public health activities. If you have one of several specific communicable diseases (for example, tuberculosis, syphilis or HIV/AIDS), information about your disease will be treated as confidential, and will be disclosed without your written permission only in limited circumstances. We may not need to obtain your permission to report information about your communicable disease to State and local officials or to otherwise use or disclose information in order to protect against the spread of the disease.
  • Within a program for activities related to the provision of substance abuse diagnosis, treatment, or referral for treatment.
  • For our use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.
  • Regarding abuse, neglect, or domestic violence; or child abuse or neglect for those in substance abuse treatment.
  • For law enforcement purposes unless otherwise prohibited by state or federal law. If you request treatment and rehabilitation for drug dependence, we will not disclose your name to any police officer or other law-enforcement officer unless you authorize such disclosure; except that if you later commit a crime or threaten to commit a crime on the premises of this agency or against program personnel, law enforcement may be notified.
  • To coroners or medical examiners when such individuals are performing duties authorized by law.
  • For court proceedings such as court orders to appear in court.
  • Related to death such as disclosure to a funeral director.
  • To avert a serious threat to the health or safety of a person or the public.
  • Related to specialized government activities such as national security.
  • To correctional institutions or other law enforcement officials when you are in their custody.
  • For Worker’s Compensation in cases pending before the Industrial Commission.
  • For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.
  • For marketing purposes. We will not use or disclose your PHI for marketing purposes.

Contacting You
Wilmington Mental Health may use your health information to contact you to:

Remind you of upcoming appointments. We may send an appointment reminder via text, or on a folded postcard to your home to remind you of a scheduled appointment. We may also send a letter to your home concerning the need for follow up care of mental health conditions.

Make you aware of alternative treatment, services, products or health care providers that may be of interest to you. If you are receiving treatment for a particular condition and your health care team learns of new or alternative treatments, we may contact you to inform you of such possibilities.

Disclosure of Health Information That Allows You An Opportunity To Object

There are certain circumstances where we may disclose your health information and you have an opportunity to object. Such circumstances include:

  • The professional responsible for your care may disclose your admission to or discharge from this agency to your next of kin
  • Disclosure to public or private agencies providing disaster relief, such as the American Red Cross.
  • Family, friends, or others that you indicate as being involved in your care or the payment for your health care. The opportunity to consent may be obtained retroactively in emergency situations.

If you would like to object to our disclosure about your health information in either of the situations listed above, please contact our agency Privacy Official listed in this Notice for consideration of your objection.


Wilmington Mental Health will not disclose your health information without your authorization except as allowed or required by state or federal law. For all other disclosures, we will ask you to sign a written authorization that allows us to share or request your health information. Before you sign an authorization, you will be fully informed of the exact information you are authorizing to be disclosed/requested and to/from whom the information will be disclosed/requested.

You may request that your authorization be cancelled by informing our agency Privacy Official that you do not want any additional health information about you exchanged with a particular person/agency. You will be asked to sign and date the Authorization Revocation section of your original authorization; however, verbal authorization is acceptable. Your authorization will then be considered invalid at that point in time; however, any actions that were taken on the authorization prior to the time you cancelled your authorization are legal and binding.

If you are a minor who has consented to treatment for services regarding the prevention, diagnosis and treatment of certain illnesses including: venereal disease and other diseases that must be reported to the State; pregnancy; abuse of controlled substances or alcohol; or emotional disturbance, you have the right to authorize disclosure of your health information. If you are a minor whose parent or guardian has consented to your treatment for substance abuse, both you and your parent or guardian must authorize disclosure of your health information. Disclosure of health information to external client advocates will require authorization by you and your personal representative if one has been designated.

No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. All the above categories exclude text messaging originator opt-in data and consent; this information will not be shared with any third parties.


You have the hollowing rights regarding your personal health information as created and maintained by this agency:

  • To Get a Paper or Electronic Copy of this Notice. At your first treatment encounter with this agency, you will be given a copy of this Notice and asked to sign an acknowledgement that you have received it. In the event of emergency services, you will be provided the Notice as soon as possible after emergency services have been provided. In addition, copies of this Notice have been posted in several public areas throughout this agency, as well as on the Wilmington Mental Health’s Internet web site at You have the right to request a paper copy of this Notice at any time from our agency Admissions Officer or our agency Privacy Official.
  • Disclosures of Your PHI. You have the right to ask us not to use or disclose certain PHI for treatment, payment, or health care operations purposes. We are not required to agree to your request and deny if we believe it would affect your health care.
  • The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.
  • The Right to Choose How I Send PHI to You. You have the right to request to be contacted at a different location or by a different method. For example, you may request all written information from this agency be sent to your work address rather than your home address. We will agree with your request as long as it is reasonable to do so; however, your request must be made in writing and forwarded to our agency Privacy Official.
  • The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that we have about you. We will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request. Your request may be denied by a professional designated by our agency director under certain circumstances. If your request is approved, you may be charged a fee to cover the costs of the copy.
  • The Right to Get a List of the Disclosures We Have Made. You have the right to request a list of instances in which we have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided us with an Authorization. We will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list we will give you will include disclosures made in the last six years unless you request a shorter time. We will provide the list to you at no charge, but if you make more than one request in the same year, we will charge you a reasonable cost-based fee for each additional request.
  • The Right to Correct or Update Your PHI. If you believe that we have information that is either inaccurate or incomplete, you may submit a request in writing to our agency Privacy Official and explain your reasons for the amendment. We will add your amendment but will not destroy the original record. We will make reasonable efforts to inform others of the changes, including persons you name who have received your PHI and who need the changes. We may deny your request, but we will explain to you in writing, within 60 days of receiving your request, the reasons for the denial and describe your rights to give us a written statement disagreeing with the denial.
  • To Request Restrictions on Uses and Disclosures of Your PHI. You have the right to request that we limit our use and disclosure of your health information for treatment, payment, and health care operations. We will make every attempt to honor your request but are not required to agree to such request. You may cancel the restrictions at any time, and we will ask that your request be in writing. In addition, this agency may cancel a restriction at any time, as long as we notify you of the cancellation.

If you believe that your privacy rights have been violated or if you are dissatisfied with our privacy policies or procedures, you may file a complaint either with us or with the federal government. We will not take any action against you or change our treatment of you in any way if you file a complaint. Suspected violations of Federal Drug and Alcohol Law may be reported to the United States Attorney in the district where the violation occurs. To file a written complaint with Wilmington Mental Health, PLLC, you may bring your complaint to your provider, his/her supervisor, the Privacy Officer or you may mail it to the following address:


3825 Market St. Ste 4, Wilmington, NC 28403
Telephone: (910) 777-5273
Fax: (910) 777-5273

The North Carolina Department of Health and Human Services has designated CARE-LINK to receive and document complaints and concerns regarding your privacy:


2012 Mail Service Center, Raleigh, NC27699-2012
Telephone: (English and Spanish): (800) 622-7030 / (919) 733-4261

You may also send a written complaint to the United States Secretary of the Department of Health and Human Services. Contact information is as follows:

U.S. Department of Health and Human Services
Office for Civil Rights

61 Forsyth Street, S.W., Suite 3B70, Atlanta, GA 30303-8909
Telephone: (404) 562-7886 / (404) 331-2867 (TDD)
Fax: (404) 562-7881

* 42 U.S.C. 290dd-3 and 42 U.S.C. 290ee-3
* 42 U.S.C. 1320d-1329d-8 and 42 U.S.C. 1320d-2(note)
* 45 CFR Parts 160 and 164. NC General Statutes – Chapter 122C, Article 3.

If you file a complaint, we will not take any action against you or change the quality of health care services we provide to you in any way. Thank you for allowing us the opportunity to serve you.