Shining Star Center for Spiritual Healing, Growth & Development

Notice of Informed Consent & Privacy Practices

Effective Date: January 16, 2015

This Notice describes how Information about you may be used and disclosed.

Please review Carefully.

How We May Use and Disclose Information About You

The following describes different ways that we use and disclose personal and medical 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 with fall within one of the following categories.

For Treatment: We may use information about you for the purpose of providing treatment or services to clinicians, counselors or caregivers involved in your care at Shining Star Center (SSC). We may also disclose your information to people outside of SSC who may be involved with your care such as friends or family members, but only if you have indicated that you wish for these persons to be informed of your treatment and care.

For Payment: We may disclose information about you so that the care and treatment services you receive may be billed by the Shining Star Center and payment collected from you, or third party payer(s) you may have or designate. However, you may request that we not disclose any information to any person(s) or entities responsible for paying for any portion of the charges you incur as a client of Shining Star Center provided that your account is paid current at the time of the request.

For Operations Purposes: We may use and disclose information about you for our operations purposes. These disclosure may be necessary for the running of SSC and to ensure that clients receive quality services. Or, in instances where information about services provided are required under the terms of any grant or outside funding for SSC. In such operations, we will remove information that personally identifies you before providing or disclosing the information.

Exceptions to Confidentiality: In the following special situations we may be required to release personal information:

1. If you threaten harm to yourself or another person, your counselor is legally, ethically, and morally required to take action to protect the safety of the threatened person. Actions could include: Informing the intended victim, arranging hospitalization for you or your child, notifying family or support system, or alerting law enforcement.

2. If abuse or neglect of a child, aged person, or disabled person is known or suspected, your counselor is required by law, to report this information to the Department of Social Services (NC) or Department of Families and Children (GA).

3. If your counselor were to receive a legally binding court order for your counseling records or for a deposition or court testimony he/she will be required to comply.

If you have any questions about this confidentiality agreement or your counseling sessions please ask your counselor.

Your Rights to Your Information

Our Obligation to you: (1.) to make certain that your personal information that identifies you is kept private, and (2.) to notify you regarding our legal duties, your legal rights, and our privacy practices at Shining Star Center, (3.) to abide by these terms of notice. You have the following rights regarding the information we maintain about you:

Right to inspect and copy: You have a right to inspect and receive a copy of your records maintained at Shining Star Center. You may be charged a fee in association with the costs of copying, and mailing, or other supplies involved with the request. Please note some information may only be kept in electronic format. If available, you may request an electronic copy.

Changes to this Privacy Notice: We reserve the right to change this notice. If we do so, we will post a copy of our current notice. The notices will contain an effective date in the top left corner of the page. If the notice changes, our website posting of the updated notice and the new effective date will serve as your notification.

Sale of confidential health or personal Information and marketing: Shining Star Center will not sell or disclose any personally identifiable information. Further we will not use your information in any marketing our advertising including using identifiable information unless specifically authorized to do so by you in writing.

Revocation of Notices: If you have previously provided us with permission to use or disclose your confidential information, you may revoke that authorization and permission at any time. To revoke your permission, you must provide a request in writing to the Shining Star Center.

Informed Consent: I consent to a counseling relationship with Dr. Margaret (Margie) Garcia-Mathier, Spiritual Counselor / Minister / Director D/B/A Shining Star Center for Healing Growth & Development. I understand that my participation is voluntary, confidentiality will be maintained, with the exceptions noted above, and that professional ethical standards of practice will be observed.

If you would like any additional information regarding the Privacy Notice and practices at Shining Star Center, you may contact us at Telephone: (828) 989-3515