Welcome to Inner Peace Psychological Services and Integrative Wellness Center.

Office Policies

Hours:
Monday, Tuesday: 9:00 to 6:00
Wednesday and Thursday: 8:40-6:00
Friday 9:00-5:00
Saturdays 9:00-2:00

1. Appointments:

• It is the responsibility of the patient to maintain their scheduled appointments schedule.
• If the patient arrives more than 15 min after the start of the appointment, they will not be able to be seen and will need to reschedule.
• If a patient "no shows" their appointment or cancels their appointment less than 24 hours in advance or two consecutive appointments, then he or she may be referred to another behavioral healthcare practice to continue treatment.

All appointments must be canceled with 24 hours' notice to Inner Peace Staff. There is a $115.00 charge for appointments that are not canceled within 24hours' notice, as well as for no show appointments.

2. Medical Records:

• A Protected Health Information Release must be completed by the patient and /or guarantor before any records are released from Inner Peace.
• This includes information from coordinating care with other providers, sharing information with spouses, parents of patients over the age of 18. Please allow 7-10 business days for records to be sent.

3. Confidentiality:

Practitioners will not share any personal information without a written consent except when required by law. Practitioners will be required to release in the following situations:

• A formal court order to release information is received.
• Child or elder abuse is occurring or there is a reason to suspect that it is occurring.
• A serious threat to harm yourself, others or property is present.
• As part of treatment, you will receive a diagnosis, it is required by the insurance company that we provide them with that diagnosis. 

4. Prescriptions:

• If you are in need of a medication refill, be sure to check with your pharmacy first to see if you have any refills left on file. If you have no refills remaining, please call Inner peace and leave a message with the administrative staff.

• Prescriptions cannot be changed vis telephone or email. You must make an appointment for any change in medication.

• Prescriptions requiring prior authorization from insurance can require an additional 48 hours to complete.
   

  Please allow 3 business days for prescription refills; DO NOT WAIT UNTIL YOU ARE OUT OF MEDICATION TO REQUEST A REFILL. IMMEDIATE REFILL REQUESTS WILL BE ASSESSED A FEE.

5. Correspondence:

• Due to increases in the amount of records processing and documentation required by many employers, insurance companies and patients, we must impose a fee of $35.00 each for letters emails, forms and phone calls to providers.
• Please allow 10-14 business days for completion of letters and paperwork related to patient care.
• Emails are not HIPAA compliant. Please call the front desk with any concerns you may have.

6. Messages:

• Please leave messages for providers with administrative staff or left in the form of a voicemail on the confidential practice voicemail.
• Please allow the office administrator's 72 hours to return your message.

7. Insurance:

• Inner Peace is in network with BCBS, CIGNA, AETNA and MEDCOST.
• Patients without health insurance and patients with an insurance carrier that is out of network will be considered self-pay
• If the patient/guardian should elect to file a claim his or her insurance carrier to seek reimbursement a copy of the required information will be given to the patient.

8. Referrals:

• If an insurance company requires a referral for office visits it is the patient's responsibility to obtain this information. Please check with your insurance provider before your visit.

9. Fees / Payment:

• No Show fee is $115.00
• Less than 24-hour cancellation is $115.00
• Letters, Emails and forms are $35.00 each.
• All copays / coinsurance is due at the time of the appointment.
• Payment in full is due at the time of the appointment.
• Inner peace accepts major credit cards, debit cards and cash. WE DO NOT ACCEPT CHECKS.
• Patients with deductibles and coinsurance will receive a bill in the mail for any balance that is owed to Inner Peace. Payment is due upon date of bill.

• If the patient is a minor, it is the responsibility of the parent or guardian accompanying the minor for payment.

• If an unaccompanied minor comes in without written consent by their parent of guardian services will be denied until it is received.

• Inner Pease will assist with a short-term payment agreement for the patient to make payments on his or her balance if the patient requests a payment plan. Non-payment of fees can result in termination of services and collection proceedings for out standing patient balances.

I have read and understand the policies implemented by Inner Peace and agree to abide by them.
I also acknowledge that I have read and received a copy of the HIPPA notice of privacy practice.

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WE ARE COMMITTED TO PROTECTING THE PRIVACY OF YOUR HEALTH INFORMATION. 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. If you have questions about this document or any other questions regarding the privacy of your medical information, please call our office at (919) 594.6510.

OUR PLEDGE REGARDING HEAL.TH INFORMATION: We are committed to protecting the privacy of health information about you and that can identify you, which we call "protected health information". Protected health information includes information about your past, present or future health, healthcare we provide you, and payment for your healthcare contained in the record of care and services provided by Inner Peace Psychological Services & Integrative Wellness Center, PLLC and its medical and administrative staff. Our privacy practices concerning your protected health information are as follows: 1) We will safeguard the privacy of protected health information that we have created or received; 2) We will explain how, when and why we use and/or disclose your protected health information, and 3) We will only use and/or disclose your protected health information as described in this Notice.

HOW WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION:
The following categories describe different ways that we may use and disclose your protected health information. Not every use or disclosure in a category will be listed.
However, all of the ways we are permitted to use and disclose information will fall within at least one of the categories.
 

For Treatment. We may use your protected health information to provide, coordinate or manage your health care treatment and related services.
Individuals Involved in Your Care or Payment for Your Care. We may use or disclose your protected health information with a person or persons involved in your medical care or payment for your care, such as a family member or a close friend. We may also notify your family about your location or general condition or disclose such information to an entity assisting in a disaster relief effort.
Other Payments. We may use and disclose your protected health information to other providers, insurance companies, consumer reporting agencies or credit bureaus so they may bill and collect payment for treatment and services they and we have provided to you.
For Health Care Operations. We may use and disclose your protected health information for health care operations. These uses and disclosures are necessary to make sure that all of our patients receive quality care and to operate and manage our office.
Appointment Reminders. We may use and disclose protected health information to provide a reminder to you about an appointment you have for treatment or medical care at Inner Peace Psychological Services & Integrative Wellness Center, PLLC.
Treatment Alternatives. We may use and disclose your protected health information to manage and coordinate your health care and inform you of treatment alternatives or health-related benefits that may be of interest to you.
Research. Under certain circumstances, we may use and disclose your protected health information for research. Before we use or disclose your protected health information for research, the project will go through a special approval process. Even without special approval, we may permit researchers to look at records to help them identify patients who may be included in their research project or for other similar purposes, as long as they do not remove or take a copy of any protected health information.
SPECIAL SITUATIONS: We may use and/or disclose protected health information about you for a number of circumstances in which you do not have to consent, give authorization or otherwise have an opportunity to agree or object. Those circumstances include:
As Required by Law. We will disclose your protected health information when required to do so by federal, state or local law or other judicial or administrative proceedings. In the event that North Carolina Law requires us to give more protection to your health information than stated in this Notice or required by Federal Law, we will give that additional protection to your health information.
To Avert a Serious Threat to Health or Safety. We may use and/or disclose your health information when necessary to prevent a serious threat your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent or reduce the threat.
Business Associates. We may disclose your protected health information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. All of our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.
Organ and Tissue Donation. We may release your protected health information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.
Military and Veterans. If you are a member of the armed forces, we may release your protected health information as required by military command authorities. We may also release this information to the appropriate foreign military authorities if you are a member of a foreign military.
Workers Compensation. We may release your protected health information for workers' compensation or similar programs that provide benefits for work-related injuries or illness.
Public Health Risks. We may disclose your health information to appropriate government authorities for public health activities. These activities include, but not limited to:
a) preventing or controlling disease, injury or disability;
b) reporting births and deaths;
c) reporting child abuse or neglect;
d) reporting reactions to medications or problems with products;
e) notifying people who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
f) notifying the appropriate government authorities if we believe a patient has been the victim of abuse, neglect or domestic violence;
g) To support public health surveillance and combat bio-terrorism. We will only make this disclosure if you agree or when required or authorized by law.
Health Oversight Activities. We may use or disclose your protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, inspections and licensures, which are necessary for the government to monitor the health care system and comply with civil rights laws.
Data Breach Notification Purposes. We may use or disclose your protected health information to provide legally required notices of unauthorized access to, or disclosure of, your health information.
​​​​Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may use or disclose your protected health information in response to a court or administrative order. We may also disclose your health information in response to a subpoena, discovery request or other lawful proves by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
​​​Law Enforcement. We may use or disclose your protected health information if asked to do so by a law enforcement official if the information is:
a) in response to a court or administrative order, subpoena, warrant, summons or similar process;
b) limited information used to identify or locate a suspect, fugitive, material witness or missing person;
c) about the victim of a crime, even if, under certain limited circumstances, we are unable to obtain the person's agreement;
d) about a death we believe may be the result of criminal conduct;
e) about criminal conduct occurring on our premises;
f) to be used in an emergency to report a crime, the location of a crime or victims, or the identity, description or location of the person suspected of committing the crime.
​​​Coroners, Medical Examiners and Funeral Directors. We may use or disclose your protected health information to a coroner or medical examiner for the purpose of identifying a deceased person or to determine the cause of death. We may also use or disclose your protected health information to funeral directors as necessary for them to carry out their duties.
National Security and Intelligence Activities. We may use or disclose your protected health information to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
Protective Services for the President and Others. We may use or disclose your protected health information to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or to conduct special investigations.
​​​​Inmates or Individuals in Custody. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release your protected health information to the correctional institution or law enforcement official.
This release is required: (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; and (3) for the safety and security of the correctional institution.

USES AND DISCLOSURES THAT REQUIRE US TO GIVE YOU AN OPPORTUNITY TO OBJECT AND CHOOSE

​​​​Disaster Relief. We may disclose your protected health information to disaster relief organizations to coordinate your care, or to notify family and friends of your location or condition in a disaster. We will provide you with an opportunity to agree or object to such a disclosure whenever possible.
 

OTHER USES OF HEALTH INFORMATION

Other uses and disclosures of health information not covered by this Notice or the laws that apply to us will be made only with your written permission. Also, when consent to disclosure is required by state law, your consent will be obtained prior to such disclosure. If you provide us permission to use or disclose your health information, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose your health information for the reasons covered by your written authorization. We are unable to take back any disclosures we have already made with your permission. We are required to retain records of the care that we provided to you.

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION: You have to following rights regarding the health information we maintain about you:

Right to an Electronic Copy of Electronic Medical Records. If your protected health information is maintained or stored in an electronic format (also known as EMR-Electronic Medical Record or EHR-Electronic Health Record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will make every effort to provide access to your protected health information in the form or format you request, if it is readily producible in such form or format. If the information is not readily producible in such form or format that you request, your information will be provided in our standard electronic format. If you do not want this form or format, your information will be provided in a readable hard copy form. We may charge you a reasonable fee for the labor associated with transmitting the electronic medical record.

Right to Get Notice of a Breach. You have the right to be notified upon a breach of any of your protected health information.

Right to Amend. You have the right to request that we make amendments to clinical, billing and other records used to make decisions about you or your health care. Your request must be in writing and must explain your reason(s) for the amendment. We may deny your request if: a) The information was not created by us, unless the person or entity that created the information is no longer available to make the amendment; b) The information is not part of the health information used to make decisions about you; c) We believe the information is correct and complete; d) You would not have the right to inspect and copy the record as described above. We will tell you in writing the reason(s) for the denial and describe your rights to give us a written statement disagreeing with the denial. If we accept your request to amend the information, we will make reasonable efforts to inform others of the amendment, including persons you name that have received your protected health information. Please submit your request for amendment in writing to: Inner Peace Psychological Services & integrative Wellness Center, PLLC at 102 Towerview Court Cary, NC 27513. Your written request should include your full name, date of birth and any other pertinent information needed to identify your record.
Right to an Accounting of Disclosures. You have the right to receive a written list of certain disclosures we made of your protected health information for purposes other than treatment, payment and health care operation or for which you provided written authorization. This does not include any disclosures made before April 14, 2003 and is limited to disclosures made within the last six (6) years. If you request this accounting more than once in a 12-month period, we may charge a reasonable cost-based fee for responding to the additional requests. To request this list or accounting of disclosures, you must submit your request in writing to: Inner Peace Psychological Services & integrative Wellness Center, PLLC at 102 Towerview Court Cary, NC 27513. Please include your full name and date of birth with your written request.
Right to Request Restrictions. You have the right to request that we restrict or limit the use and disclosure of your protected health information with regards to treatment, payment or health care operations as well as disclosure to someone involved in your care or payment for your care. We are not required to agree to your requested restrictions unless you are asking us to restrict the use and disclosure of your protected health information to a health plan for payment or health care operation purposes, and such information you wish to restrict pertains solely to a health care item or service for which you have paid us "out-of-pocket" in full. If we agree, we will comply with your request unless the information is needed a) to provide you with emergency treatment, b) for disclosure to the Secretary of the Department of Health and Human Services and/or c) uses and disclosures that do not require your authorization. You may request a restriction by submitting the request in writing to: Inner Peace Psychological Services & integrative Wellness Center, PLLC at 102 Towerview Court Cary, NC 27513. Please include your full name and date of birth with the request.
Right to an Electronic Copy of Electronic Medical Records. If your protected health information is maintained or stored in an electronic format (also known as EMR-Electronic Medical Record or EHR-Electronic Health Record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will make every effort to provide access to your protected health information in the form or format you request, if it is readily producible in such form or format. If the information is not readily producible in such form or format that you request, your information will be provided in our standard electronic format. If you do not want this form or format, your information will be provided in a readable hard copy form. We may charge you a reasonable fee for the labor associated with transmitting the electronic medical record.

Right to Get Notice of a Breach. You have the right to be notified upon a breach of any of your protected health information.
Right to Amend. You have the right to request that we make amendments to clinical, billing and other records used to make decisions about you or your health care. Your request must be in writing and must explain your reason(s) for the amendment. We may deny your request if: a) The information was not created by us, unless the person or entity that created the information is no longer available to make the amendment; b) The information is not part of the health information used to make decisions about you; c) We believe the information is correct and complete; d) You would not have the right to inspect and copy the record as described above. We will tell you in writing the reason(s) for the denial and describe your rights to give us a written statement disagreeing with the denial. If we accept your request to amend the information, we will make reasonable efforts to inform others of the amendment, including persons you name that have received your protected health information. Please submit your request for amendment in writing to: Inner Peace Psychological Services & integrative Wellness Center, PLLC at 102 Towerview Court Cary, NC 27513. Your written request should include your full name, date of birth and any other pertinent information needed to identify your record.
Right to an Accounting of Disclosures. You have the right to receive a written list of certain disclosures we made of your protected health information for purposes other than treatment, payment and health care operation or for which you provided written authorization. This does not include any disclosures made before April 14, 2003 and is limited to disclosures made within the last six (6) years. If you request this accounting more than once in a 12-month period, we may charge a reasonable cost-based fee for responding to the additional requests. To request this list or accounting of disclosures, you must submit your request in writing to: Inner Peace Psychological Services & integrative Wellness Center, PLLC at 102 Towerview Court Cary, NC 27513. Please include your full name and date of birth with your written request.

Contact for Questions or Complaints:

If you have any questions regarding this notice or if you believe your privacy rights have been violated or wish to file a complaint about our privacy practices, you may contact the Practice Manager by telephone at (919) 594-6510, or in writing to Inner Peace Psychological Services & integrative Wellness Center, PLLC at 102 Towerview Court Cary, NC 27513. Please provide your full name and date of birth with your request/ complaint. You may also send a written complaint to the United States Secretary of the Department of Health and Human Services. You will not be penalized for filing a complaint.

Changes to This Notice

We reserve the right to change the terms of this notice and to make new notice provisions effective for all protected health information that we maintain by: 1) Posting the revised notice at our facilities; and/ or2) making copies of the revised notice available upon request ( either at our facilities or through the contact listed in the notice).

Please sign to acknowledge that you have read and have received a copy of this Notice of Privacy Practices-HIPPA

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