Experienced, Caring Professionals
Helping You Reach Your Potential
Experienced, Caring Professionals
Helping You Reach Your Potential

Patient Forms via Patient Portal

For medical offices ONLY, please use the following referral form: Provider Referral Form (not for Patient use)



All Patient Forms are available to be filled out electronically in the Patient Portal. In order to access the Patient Portal, you will need to register for an account. Our system will automatically email new Patients with a registration link, but all Patients have the ability to create an account via the Patient Portal. Once you are at the Patient Portal screen, click on the blue Register button to create an account. If you are unable to access the Patient Portal, you can email our front desk and they can send you the forms to be printed and completed prior to your appointment – send email to: adminassist@carterpsych.com to receive printable forms.  



You now have the right to restrict certain disclosures of Protected Health Information (PHI) by CPC to your insurance carrier or health plan.

Without this restriction your insurance company or other payer may access your entire record. To exercise this right you must choose to pay out-of-pocket in full. To exercise this right, simply talk to your doctor. You may be surprised by how little this costs.

Examples of uses of your health information for treatment purposes are:

  • An employee of the provider’s office obtains treatment information about you and records it in a health record.
  • During the course of your treatment, the provider determines that he/she will need to consult with another specialist in the area. He/She will share the information with such specialists and obtain his/her input.

An example of use of your health information for payment purposes:

  • We submit a request for payment to your health insurance company. The health insurance company requests information from us regarding services rendered. We will provide that information to them about you and the care you receive.
  • We verify insurance coverage prior to your first appointment and obtain prior authorization and precertification when required to do so by your policy coverage.
  • We provide information to agents we retain to collect past due fees.

An example of use of your health information for health care operations:

  • The state licensing authority wants to review records to assure that we have acted consistent with state law regarding your care. In doing so, it wants to take a sampling which includes review of your chart. At the licensing authority’s request, we will provide it with a copy of your chart.
  • Employees and Business Associates of Carter Psychology Center may access and/or share protected health information.


The health record and billing records we maintain are the physical property of this office. The information in it, however, belongs to you. You have a right to:

  • Request a restriction on certain uses and disclosures of your protected health information by delivering the request in writing to our office. We are not required to grant the request, but we will comply with any request that is granted.
  • Obtain a paper copy of the Notice of Privacy Practices for Protected Health Information by making a request at our office.
  • Request that you be allowed to inspect and receive a copy of your health record and billing record in electronic or other mutually agreeable form. You may exercise this right by delivering the request in writing to our office using the form we provide to you upon request.
  • Appeal a denial of access to your protected health information.
  • Request that your health care record be amended to correct incomplete or incorrect information by delivering a written request to our office using the form we provide to you upon request.
  • File a statement of disagreement if your amendment is denied, and require that the request for amendment and any denial be attached in all future disclosures of your protected health information.
  • Obtain an accounting of disclosures of your health information as required to be maintained by law by delivering a written request to our office using the form we provide to you upon request. The accounting will not include internal uses of information for treatment, payment, or operations, disclosures made to you or made at your request.
  • Request that communication of your health information be made by alternative means or at an alternative location by delivering the request in writing to our office using the form we provide to you upon request.
  • Revoke any authorizations that you made previously to use or disclose information except to the extent information or action has already been taken by delivering a written revocation to our office.
  • You now have the right to be notified if there is breach of certain unsecured information. Effective October 2013 CPC will be converting to a deeply encrypted electronic medical record to best protect this information.


The provider is required to:

  • Maintain the privacy of your health information as required by law.
  • Provide you with a notice as to our duties and privacy practices as to the information we collect and maintain about you.
  • Abide by the terms of this Notice.
  • Notify you if we cannot accommodate a requested restriction or request.
  • Accommodate your reasonable requests regarding methods to communicate health information to you.

We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain. If our information practices change, we will amend our Notice to reflect these changes. You are entitled to receive a revised copy of the Notice by calling or requesting a copy of our Notice or by visiting the office to obtain a copy.

To Request Information or File a Complaint

If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact the following person: Michael Spellman at 941-753-0064 You may also file a complaint by mailing or e-mailing it to the Secretary of Health and Human Services at 202-619-0257 We cannot, and will not, require you to waive the right to file a complaint with the Secretary of Health and Human Services (HHS) as a condition of receiving treatment from our office. We cannot, and will not, retaliate against you for filing a complaint with the Secretary.

Other Uses and Disclosures

  • We have Business Associates with whom we may share your protected health information.
  • For example, in preparing our annual financial statement, auditors may need to review samples of medical care given.
  • For example, during our routine health care operations, we may need to hire computer technicians and software vendors. We may disclose your health information to these vendors to maintain daily functioning in our health care operations.

Unless you object in writing, we may use or disclose your protected health information to notify, or assist in notifying, a family member, personal representative, or other persons responsible for your care including any doctor who you inform us is involved in your care, about your location, about your general condition, about your diagnosis and treatment or your death.