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.
Medical records requests require up to 14 business days to fulfill.
A medical records form must be either:
-completed in our office in it’s entirety, signed by the patient or legal representative, witnessed by
a CCNC employee and dated appropriately.
-we will accept a completed, HIPAA compliant request form from another doctor’s office or entity.
The fee schedule is as dictated by the North Carolina General Statutes 90-411 and is as follows:
$0.75 per page; pages 1-25
$0.50 per page; pages 26-100
$0.25 per page; pages 101 and up
$10.00 minimum fee
To pick up medical records requests, the person picking up the records must be the patient or an authorized individual on the patient’s account, must sign for the documents, submit payment (if not already received) and produce a picture ID to confirm identity.
It is the responsibility of the patient to attend all scheduled appointments and arrive in a timely fashion. Should a patient not be able to attend an appointment, a 24 hour notice is requested. If a patient fails to call to cancel an appointment in advance or fails to attend a scheduled appointment, a service fee of $25.00 may be charged. CCNC does understand there are sometimes extenuating circumstances and those will be taken into consideration.
Should a client perpetually no show their appointments, CCNC reserves the right to decline any further services.
If you are having a life threatening emergency, please call 911 or go to the nearest emergency room!
If you are having a non-life threatening emergency after our business hours, please call 911 or Good Hope Hospital at (910) 230-4011.
If a current patient needs a refill of medication or as a non-emergency medication issue, please call our office, select option 2 and leave a detailed message, including the patient’s name, date of birth, and a telephone number to return your call. If the caller is not the patient, he/she must include his/her name and relationship to the patient.
Always allow a minimum of 72 hours to refill requests and for completion of medical and school forms. Please be aware that we will only return calls to a patient or someone with whom the patient has given us written authorization to speak.
We are currently contracted with BCBS-NC, TriCare, NC HealthChoice, Medicaid (Carolina Access only for adults), Medicare and MedCost. Of course this list may change without notice. We ask for payment in full at the time of service until your deductible is met. Refunds on accounts with a credit balance will be made periodically or upon request (allow 14 days for processing). We do file insurance claims for you to the carrier indicated in your account.
We request and insist all co-payments/co-insurance are to be paid at the time of service. We are obligated by our contract with insurance carriers to collect co-pays/co-insurance at the time of service -that requirement is in your contract and ours. This policy is effective regardless of who is accompanying the patient. We do accept Master Card and Visa as a courtesy to our patients.
We have unfortunately encountered numerous problems with payment for services in cases of children whose parents are divorced. The adult bringing the child to the office is responsible for payment on that day. We realize this can be a difficult situation for all concerned; however, we cannot serve as an intermediary.
Providing quality mental health care is a complex task which requires close cooperation between patients and health facility personnel. Patients can take responsibility for their care by helping the medical team give the best possible care.
These patient responsibilities are:
1. Providing Information. The responsibility to provide, to the best of your knowledge, accurate and complete information about complaints, past illness, hospitalizations, medications, and other matters relating to the patient’s health. A patient has the responsibility to let his/her health care provider know whether he or she understands the treatment and what is expected of him/her.
It is the patient’s responsibility to notify us of any changes to their contact information and insurance.
2. Respect and Consideration. The responsibility for being considerate of the rights of other patients and health care personnel and for assisting in the control of noise, smoking, and the number of visitors. The patient is responsible for being respectful of the property of other persons and of the property of the facility.
We ask that patients refrain from using profanity or raised voices. Keep cell phone usage to a minimum in the waiting area and turn off cell phones while in the clinical areas.
3. Compliance with Medical Care. The responsibility for complying with the medical and nursing treatment plan, including follow up care recommended by health care providers. This includes keeping appointments on time and notifying the health facility when appointments cannot be kept.
4. Medication Management. Patients and/or their family members have the responsibility to ask the health care provider what to expect regarding their medication management and to participate in discussion and decisions. Patients should ask and notify the health care provider if symptoms are not relieved; share their concerns.
5. Rules and Regulations. The responsibility for following the rules and regulations effecting patient care and conduct.
6. Reporting of Patient Concerns. The responsibility for helping CCNC provide the best possible care to all beneficiaries. Patient’s recommendations, questions or concerns should be reported to the Front Office Supervisor or the Assistant Practice Manager.
CCNC does not discriminate on the basis of race, color, national origin, sex, age, or disability in its health programs and activities; (2) CCNC provides appropriate auxiliary aids and services, including qualified interpreters for individuals with disabilities and information in alternate formats, free of charge and in a timely manner, when such aids and services are necessary to ensure an equal opportunity to participate to individuals with disabilities; (3) CCNC provides language assistance services, including translated documents and oral interpretation, free of charge and in a timely manner, when such services are necessary to provide meaningful access to individuals with LEP; (4) how to obtain such auxiliary aids and services and such language assistance services; (5) an identification of, and contact information for, the responsible employee designated by the covered entity to coordinate its efforts to comply with and carry out its responsibilities under Section 1557 and the Final Rule; (6) the availability of the grievance procedure and how to file a grievance; and (7) how to file a discrimination complaint with OCR. You may view the translation in the footer below.