Policy 104: Privacy Policy

Purpose: The purpose of this policy is to ensure the protection of health information, medical records, patient rights, and HIPAA compliance as described by state and federal law. Additionally, this policy describes the use, disclosure, and accessibility of health information.

Policy: Carolina Recovery Solutions is required by state and federal law to protect the privacy of client health information that may identify the client. This health information includes mental health, developmental disability and/or substance abuse services that are provided to the client, payment for those health care services, or other health care operations provided on the client’s behalf.

This agency is required by law to inform the client of our legal duties and privacy practices with respect to health information through this Notice of Privacy Practices. This Notice describes the ways we may share the client’s 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 office.Copies of any revised Notices will be available to you upon request.

If at any time, the client has questions or concerns about the information in this Notice or about our agency’s privacy policies, procedures and practices, the client may contact our agency Privacy Official at (828)785-5745


Use and Disclosure of Health Information without Client Authorization

  • Treatment

Carolina Recovery Solutions 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 our agency.

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. [The following is based upon State law (GS 90-109.1) and applies to substance abuse providers, “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.”]

  • Payment for Services

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.

  • Health Care Operations

Carolina Recovery Solutions 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 evaluate 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.
  • Provide information to professional organizations that evaluate, certify or license health care providers, staff or facilities.
  • Allow our agency attorney to use your health information when representing this agency in legal matters.
  • Resolve grievances within our agency.
  • Provide information to your internal client advocate who is available to represent your interests upon your request.
  • Other Circumstances

Carolina Recovery Solutions 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:

  • Required by law;
  • For public health activities. For example, we may disclose health information to public health authorities if you have a communicable disease and we have reason to believe, based upon information provided to us, that there is a public health risk such as evidence of your non-compliance with your treatment plan. If you suffer from a communicable disease such as tuberculosis or HIV/AIDS, information about your disease will be treated as confidential. Other than circumstances described to you in other sections of this Notice, we will not release any information about your communicable disease except as required to protect public health or the spread of a disease, or at the request of the State or Local Health Director;
  • Regarding abuse, neglect or domestic violence; (Not applicable to substance abuse providers – for substance abuse providers say “Regarding child abuse or neglect”)
  • For law enforcement purposes unless otherwise prohibited by state or federal law; [Not applicable to substance abuse providers – for substance abuse providers say, “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.”]
  • For court proceedings such as court orders to appear in court;
  • Related to death such as disclosure to a funeral director;
  • Related to donation of organs or tissue;
  • 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.
  • Disclosure of Client Health Information That Allows Client 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:

  • Disclosure to public or private agencies providing disaster relief.

If a client would like to object to our disclosure about your health information in the situations listed above, the client can contact our agency Privacy Official listed for consideration of the client's objection.

  • Disclosure of Client Health Information That Requires Client Authorization

Carolina Recovery Solutions will not disclose a client’s health information without authorization except as allowed or required by state or federal law. For all other disclosures, we will ask a client to sign a written authorization that allows us to share or request the client’s health information.

Before a client signs an authorization, the client will be fully informed of the exact information the client is authorizing to be disclosed/requested and to/from whom the information will be disclosed/requested.

A client may request that the client’s 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. The client will be asked to sign and date the Authorization Revocation section of the client’s original authorization; however, verbal authorization is acceptable. The client’s authorization will then be considered invalid at that point in time; however, any actions that were taken on the authorization prior to the time the client cancelled authorization are legal and binding.

  • Client Rights Regarding Health Information
    • You have the following rights regarding your health information as created and maintained by this agency.
    • Right to receive a copy of the Privacy Notice
    • The client has the right to receive a copy of Carolina Recovery Solutions Notice of Privacy Practices. At the client’s first treatment encounter with this agency, the client will be given a copy of the Privacy Notice and asked to sign an acknowledgement that the client has received it. In the event of emergency services, the client 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.The client has the right to request a paper copy of this Notice at any time from our agency Admissions Officer or our agency Privacy Official.
  • Right to request different ways to communicate with you

The client has the right to request to be contacted at a different location or by a different method. Carolina Recovery Solutions 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.

  • Right to request to see and copy your health information
    • The client has the right to request to see and receive a copy of your health information in medical, billing and other records that are used to make decisions about the client. The client’s request must be in writing and forwarded to our agency Privacy Official. The client can expect a response to the request within 30 days.
    • If the request is approved, the client may be charged a fee to cover the cost of the copy. Instead of providing you with a full copy of your health information record, we may give you a summary or explanation of your health information, if you agree in advance to that format and to the cost of preparing such information.
    • Client requests may be denied by the physician or a professional designated by our agency director under certain circumstances.
    • If requests are denied, we will explain our reason for doing so in writing and describe any rights the client may have to request a review of our denial. In addition, the client has the right to contact our agency Privacy Official to request that a copy of your health information be sent to a physician or psychologist of your choice.
    • Whenever the client has a personal representative who consented to treatment, the personal representative has the same rights to request to see and copy the client’s health information.
  • Right to request amendment of your health information
    • The client has the right to request changes in their health information in medical, billing and other records used to make decisions about the client. If the client believes that information that Carolina Recovery Solutions has is either inaccurate or incomplete, the client may submit a request in writing to our agency Privacy Official and explain the client’s reasons for the amendment.
    • Carolina Recovery Solutions must respond to the client’s request within 30 days of receiving the client’s initial written request. If we accept the client’s request to change health information, we will add the client’s amendment but will not destroy the original record.
    • In addition, we will make reasonable efforts to inform others of the changes, including persons who the client name who have received the client’s health information and who need the changes.

We may deny your request if:

  • The information was not created by this agency (unless you prove the creator of the information is no longer available to change the information);
  • The information is not part of the records used to make decisions about you;
  • We believe the information is correct and complete; or
  • Your request for access to the information is denied.
  • If we deny the client’s request to change health information, we will explain to the client in writing the reasons for denial and describe the client's rights to give us a written statement disagreeing with the denial. If the client provides a written statement, the statement will become a permanent part of the client’s record. Whenever disclosures are made of the information in question, the client’s written statement will be disclosed as well.
  • Right to request a listing of disclosures we have made

The client has a right to a written list of disclosures of the client’s health information. The list will be maintained for at least six years for any disclosures made after April 14, 2003. This listing will include the date of the disclosure, the name (and address, if available) of the person or organization receiving the information, a brief description of the information disclosed and the purpose of the disclosure.

This agency is not required to include the following on the list of disclosures:

  • Disclosure for your treatment;
  • Disclosure for billing and collection of payment for your treatment;
  • Disclosures related to our health care operations;
  • Disclosures that you authorized;
  • Disclosures to law enforcement when you are in their custody; or
  • Disclosures made to individuals involved in your care.

The client’s first request for a listing of disclosures will be provided to the client free of charge. However, if the client requests a listing of disclosures more than once in a 12 month period, the client may be charged a reasonable fee. We will inform the client of the cost involved and the client may choose to withdraw or modify their request at that time, before any costs are incurred.

  • Right to request restrictions on uses and disclosures of your health information

The client has the right to request that we limit our use and disclosure of their health information for treatment, payment and health care operations. The client also has the right to request a limit on the health information we disclose about the client to their next of kin or someone who is involved in their care. We will provide the client with a form to document the request.

We will make every attempt to honor the client’s request but are not required to agree to such request. However, if we do agree, we must follow the agreed upon restriction (unless the information is necessary for emergency treatment or unless it is a disclosure to the U.S. Secretary of the Department of Health and Human Services).

The client may cancel the restrictions at any time and we will ask that the request be in writing. In addition, this agency may cancel a restriction at any time, as long as we notify the client of the cancellation.


(Applicable to substance abuse providers – “Violation of the Federal law and regulations relative to a substance abuse program is a crime. Suspected violations may be reported to our agency Privacy Official who will report the violation to appropriate authorities in accordance with Federal regulations.”)

If the client believes we have violated their privacy rights, or if the client wants to file a complaint regarding our privacy practices, the client may contact our agency Privacy Official. Contact information is as follows:

Carolina Recovery Solutions Privacy Official

Clinical Director

Agency Address

901 Old Mars Hill Hwy Ste. 5 Weaverville, NC 28787

Agency Phone Number


Agency Fax Number


The North Carolina Department of Health and Human Services operates an information and referral service located in the Office of Citizen Services, known as CARE-LINE, which has been designated to receive and document complaints and concerns regarding your privacy. Contact information is as follows:


2012 Mail Service Center

Raleigh, NC 27699-2012

Voice Phone (English and Spanish):

1-800-662-7030 (Toll Free)

(919) 733-4261 (Triangle Area and Out of State)

FAX: (919) 715-8174

TTY: 1-877-452-2514 (TTY Dedicated)

(919) 733-4851 (TTY Dedicated for local or out of state calls)

Email: care.line@ncmail.net

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:

Office for Civil Rights

U.S. Department of Health and Human Services

Atlanta Federal Center, Suite 3B70

61 Forsyth Street, S.W.

Atlanta, GA 30303-8909

Voice Phone: (404) 562-7886

FAX: (404) 562-7881

TDD: (404) 331-2867

If a client files a complaint, we will not take any action against the client or change the quality of health care services we provide to the client in any way.

Legal References

Primary Federal and State laws and regulations that protect the privacy of your health information are listed below.

Confidentiality of Alcohol and Drug Abuse Patient Records – 42 U.S.C. 290dd-3 and 42 U.S.C. 290ee-3 for Federal laws and 42 CFR Part 2 for Federal regulations.

Health Insurance Portability and Accountability Act (HIPAA), Administrative Simplification, Privacy of Individually Identifiable Health Information – 42 U.S.C. 1320d-1329d-8 and 42 U.S.C. 1320d-2(note) for Federal laws and 45 CFR Parts 160 and 164 for Federal regulations.

NC General Statutes – Chapter 122C, Article 3 (Client’s Rights and Advance Instruction), Part 1 (Client’s Rights). Chapter 90 (Medicine and Allied Occupations), Article 1 (Practice of Medicine).

NC Administrative Code – 10 NCAC 18 D (Confidentiality Rules).