NC POP Provider Agency and Clinician License Agreement

  1. Business Associate Agreements
  2. I understand that my relationship with the NC Child Treatment Program (NC CTP) and its parent organization the Center for Child and Family Health (CCFH) is governed by the Business Associate Agreement (BAA) signed by my Agency. In the event that I move to another Agency in the future, I understand that no relationship with NC CTP or CCFH will exist until a new BAA is signed between that new Agency and CCFH. I understand that the requirement to sign a new BAA will apply if I am in independent practice, under which I will be considered an Agency.

  3. NC Performance and Outcome Platform (NC POP)
    1. Information to be disclosed into NC POP, including authorized access to data
      1. I understand that NC POP is a HIPAA-compliant, web-based clinical tool used to guide fidelity monitoring; it is not intended to guide treatment delivery.
      2. I understand that NC POP contains client-specific data that I will enter, as well as client-specific data will be scored, aggregated, displayed, and/or stored (the "Data"). Clinical staff and agency administrators may also enter Data and/or stored in NC POP. The Data may include personally identifiable information, including Protected Health Information (PHI), which is individually identifiable health information maintained by a covered entity or business associate and relates to an individual's past, present, or future physical or mental condition.
      3. I acknowledge that accuracy of the Data entered is my sole responsibility
      4. I further acknowledge that I assume sole responsibility for all aspects of client care, including proper interpretation and/or use of data entered, scored, aggregated, displayed, and/or stored, in NC POP.
      5. I understand that data that I enter in NC POP is not necessarily monitored by NC CTP faculty or staff. Neither NC CTP, not its faculty and staff, nor its parent organization, the Center for Child and Family Health (CCFH), will participate directly or indirectly, not support, any aspect of client care, including the provision of clinical supervision.
      6. Notwithstanding this acknowledgement, I represent that the use of PHI that I input into NC POP is authorized under HIPAA or I have obtained the necessary consent from each of my clients to for such use. CCFH does not disclose, give, sell, or transfer any Data unless required for law enforcement or otherwise required by law.
      7. For clinicians actively engaged in TF-CBT training through the North Carolina Child Treatment Program only: My training consultant may not have access to any or all clinical data that I entered into NC POP during the training period. *
    2. State of North Carolina Ownership and LME/MCO Access to NC POP Data
    3. I understand that, for the purposes of population and quality service monitoring, designated personnel within the North Carolina Division of Mental Health/Developmental Disabilities/Substance Abuse Services (NC DMN/DD/SAS) may have access to my client's personally identifiable information, including Protected Health Information (PHI), which I have entered into the NC POP system. Furthermore, designated personnel within the statewide network of Managed Core Organizations (MCOs) may have access to personally identifiable information, including PHI, for those Medicaid or Health Choice clients within the MCO's catchment area. Designated NC DMH/DD/SAS and MCO personnel have such access to NC POP data by law [North Carolina General Assembly S.L. 2013-360:S402 Appropriations Act of 2013 (12F.3.(b))] whereby "Nonrecurring funds appropriated in this act to the Department of Health and Human Services, Division of Mental Health, Developmental Disabilities, and Substance Abuse Services, for the 2013-2015 fiscal biennium for the North Carolina Child Treatment Program (NC CTP) shall be used to pay for the cost of developing a secure database for the NC CTP to track individual-level and aggregate-level data with interface capability to work with existing networks within State agencies. The data, including any entered or stored in the database, is and remains the sole property of the State."

  4. Signed Consent on File
  5. Prior to providing any Data hereunder, I have obtained, and will maintain on file in accordance with HIPAA and any other applicable state and federal laws, signed client and legal guardian consent to include, as appropriate, acknowledgement of:

    1. Information to be disclosed into NC POP, including authorized access to data
    2. State of North Carolina Ownership and LME/MCO Access to NC POP Data