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General Information

Information regarding your health care, including payment for health care, is protected by two federal laws; the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 42 U.S.C. 1320 det seq,, 45 C.F.R. Part 160 & 164 and the confidentiality Law, 42 U.S.C. 290dd-2, 42 C.F.R. Part 2. Under theses laws, Center for Emotional Health may not say to a person outside of Center for Emotional Health that you receive treatment from CEH, nor may Center for Emotional Health disclose any information identifying you as a CEH patient, or disclose any other protected information except as permitted by federal law. Center for Emotional Health must obtain your written consent before it can disclose information about you for any purpose. For example, Center for Emotional Health must obtain your written consent before it can disclose information to your health insurer in order to be paid for services. Generally, you must also sign a written consent before Center for Emotional Health can share information for treatment purposes or for health care operations. However, federal law permits Center for Emotional Health to disclose information without your written permission in the following situations:

1. Pursuant to an agreement with a qualified service organization/ business associate
2. For research, audit or evaluations.
3. To report a crime committed on Center for Emotional Health premises or against Center for Emotional Health personnel.
4. To medical personnel in a medical emergency.
5. To appropriate authorities to report suspected child abuse or neglect or domestic violence.
6. As allowed by a court order.

For example, Center for Emotional Health can disclose information without your consent to obtain legal or financial services, or to another medical facility to provide health care to you, as long as there is a qualified services organization/ business associate agreement in place. Center for Emotional Health may need to share your protected health information with third party “business associates” that perform various activities such as laboratory services. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information. Before Center for Emotional Health can use or disclose any information about your health in a manner which is not described above, it must first obtain your specific written consent allowing it to make the disclosure. Any such written consent may be revoked by you in writing at any time.

Your Rights:

Under HIPAA you have the right to request restrictions on certain uses and disclosures of your health information. At your request, Center for Emotional Health will not disclose information to your health insurance plan about any services for which you have paid out-of-pocket. Center for Emotional Health is not required to agree to any other restrictions you request, but if it does agree, then it is bound by that agreement and may not use or disclose any information which you have restricted except as necessary in a medical emergency. You have the right to request that we communicate with you by alternative means or at an alternative location. Center for Emotional Health will accommodate such requests that are reasonable and will not request an explanation from you. Under HIPAA you also have the right to inspect and copy your own health information maintained by Center for Emotional Health, except to the extent that the information contains psychotherapy notes or information compiled for use in a civil, criminal or administrative proceeding or in other limited circumstances.

Under HIPAA you also have the right, with some exceptions, to amend health care information maintained in Center for Emotional Health records, and to request and receive an accounting of disclosures of your health related information made by Center for Emotional Health during the six years prior to your request. You also have the right to receive a paper copy of this notice.

Center for Emotional Health’s Duties:

Center for Emotional Health will not share your protected health information for marketing or fundraising purposes, nor will we ever sell your protected health information without your prior approval. Center for Emotional Health is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. Center for Emotional Health is required by law to abide by the terms of this notice. Center for Emotional Health reserves the right to change the terms of this notice and to make new notice provisions effective for all protected health information it maintains. You may access a revised version by requesting a copy by calling our office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.

Questions or Grievances:

If you want more information about our privacy practices or have questions or concerns, please contact our office at 704-237-4240 or by email at
Info@cehcharlotte.com

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or n response to a request you made to amend or restrict the use of disclosure of your health information or to have us communicate with you by alternative means or at alternative locations. You may use the contact information listed at the end of this Notice. You also may submit a written grievance to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.
We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or the U.S. Department of Health and Human Services. If you have any questions or comments regarding your Protected Health Information, feel free to contact our office. The contact information is provided below.

CEH Office: 704-237-4240;
Phone or 704-841-3889;
Address: 280 Executive Park Drive, Suite 100, Concord NC 28025

The FDA has not approved suboxone/buprenorphine as completely safe for use during pregnancy. The decision on whether or not to continue the medication during pregnancy must be made after a full and open discussion of the risks and benefits of that decision.

It is important that you inform your doctor if you are now or intend to become pregnant.

Suboxone/buprenorphine can be a way to maintain pregnancy as healthfully as possible while also stopping the use of the opiate of choice without triggering withdrawal symptoms that may cause a spontaneous abortion. Throughout the pregnancy, your infant could become dependent on the drug. This can cause life-threatening withdrawal symptoms in the infant after the infant is born. Adequate advance planning will allow for the greatest physical and mental well-being of mother and infant.

I understand that Dr. Stoudmire is prescribing Vivitrol/Naltrexone to manage my alcohol dependence or opioid dependence. The risks, side effects, and benefits of treatment have been explained to me, and I agree to the following instructions. Failure to follow these instructions may result in not having the medication prescribed.

1. I will participate in any other treatments recommended by my provider, including group therapy.

2. I will take my medications exactly as prescribed and will not change the medication or dosage without advance approval from any provider. I will provide my medication for pill counts at the provider’s request. I will not request early refills.

3. I will keep regular appointments with my provider.

4. I will inform my provider within one business day if I am hospitalized for any reason, or if I have another condition that requires the prescription of a controlled drug (like narcotics, tranquilizers, barbiturates, or stimulants).

5. I will choose one pharmacy where all my prescriptions will be filled.

6. I understand that lost or stolen prescriptions will not be replaced, so I will keep my prescription and medication in a safe place or lock box.

7. I agree to avoid all illegal and recreational drugs (including alcohol) and will provide urine or blood specimens at the doctor’s request to monitor my compliance.

8. I agree to follow my doctor’s recommendations regarding the operation of motor vehicles or heavy machinery while taking this medication.

9. Refills will be made only during regular office hours, which are Monday-Friday from 8 am to 5 pm. Refills will not be made at night, on weekends or during holidays. I am responsible for keeping track of my remaining medication, so that I can call for refills in advance. This way, I will not run out of medication.