NOTICE OF PRIVACY PRACTICES
Effective
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE
USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
We may use or
disclose your
protected health information (PHI),
for treatment, payment, and health care
operations purposes with your consent.
To help clarify these terms, here are some definitions:
·
“PHI” refers to information in your
health record that could identify you.
·
“Treatment, Payment, and Health Care
Operations”
– Treatment is when we provide,
coordinate, or manage your health care and other services related to your health
care. An example of treatment would
be when we consult with another health care provider, such as your family
physician or another psychologist.
– Payment is when we obtain
reimbursement for your healthcare.
Examples of payment are when we disclose your PHI to your health insurer to
obtain reimbursement for your health care or to determine eligibility or
coverage.
– Health Care Operations are
activities that relate to the performance and operation of our practice.
Examples of health care operations are quality assessment and improvement
activities, business-related matters such as audits and administrative services,
and case management and care coordination.
·
“Use” applies only to activities
within our practice group, such as sharing, employing, applying, utilizing,
examining, and analyzing information that identifies you.
·
“Disclosure” applies to activities
outside of our practice group, such as releasing, transferring, or providing
access to information about you to other parties.
We may use or disclose PHI for purposes outside of treatment, payment, or health
care operations when your appropriate authorization is obtained.
An “authorization” is written
permission above and beyond the general consent that permits only specific
disclosures. In those instances
when we are asked for information for purposes outside of treatment, payment or
health care operations, we will obtain an authorization from you before
releasing this information. We will
also need to obtain an authorization before releasing your Psychotherapy Notes.
“Psychotherapy Notes” are
notes we have made about our conversation during a private, group, joint, or
family counseling session, which we have kept separate from the rest of your
medical record. These notes are
given a greater degree of protection than PHI.
You may revoke all such authorizations (of PHI or Psychotherapy Notes) at any
time, provided each revocation is in writing.
You may not revoke an authorization to the extent that (1) we have relied
on that authorization; or (2) if the authorization was obtained as a condition
of obtaining insurance coverage; or (3) if the law provides the insurer the
right to contest the claim under the policy.
We may use or disclose PHI without your consent or authorization in the
following circumstances:
·
Child Abuse
– If we have reasonable cause to suspect child abuse or neglect, we must report
this suspicion to the appropriate authorities as required by law.
·
Adult and Domestic Abuse
– If we have reasonable cause to suspect you have been criminally abused, we
must report this suspicion to the appropriate authorities as required by law.
·
Health Oversight Activities
– If we receive a subpoena or other lawful request from the Department of Health
or the Michigan Board of Psychology, we must disclose the relevant PHI pursuant
to that subpoena or lawful request.
·
Judicial and Administrative Proceedings
– If you are involved in a court proceeding and a request is made for
information about your diagnosis and treatment or the records thereof, such
information is privileged under state law, and we will not release information
without your written authorization or a court order.
The privilege does not apply when you are being evaluated or a third
party or where the evaluation is court ordered.
You will be informed in advance if this is the case.
·
Serious Threat to Health or Safety
– If you communicate to us a threat of physical violence against a reasonably
identifiable third person and you have the apparent intent and ability to carry
out that threat in the foreseeable future, we may disclose relevant PHI and take
the reasonable steps permitted by law to prevent the threatened harm from
occurring. If we believe that there
is an imminent risk that you will inflict serious physical harm on yourself, we
may disclose information in order to protect you.
If there is a medical emergency, we will disclose such PHI information to
emergency medical personnel as is necessary to obtain treatment for you.
·
When Legally Required.
We will disclose your projected health information when we are required to do so
by any Federal, State or local law.
·
Worker’s Compensation
– We may disclose protected health information regarding you as authorized by
and to the extent necessary to comply with laws relating to worker’s
compensation or other similar programs, established by law, that provide
benefits for work-related injuries or illness without regard to fault.
Client’s Rights:
·
Right to Request Restrictions
– You have the right to request restrictions on certain uses and disclosures of
protected health information.
However, we are not required to agree to a restriction you request.
·
Right to Receive
Confidential Communications by
Alternative Means and at Alternative Locations –
You have the right to request and receive confidential communications of PHI
by alternative means and at alternative locations.
(For example, you may not want a family member to know that you are
seeing us. On your request, we will
send your bills to another address.)
·
Right to Inspect and Copy
– You have the right to inspect or obtain a copy (or both) of PHI in our mental
health and billing records used to make decisions about you for as long as the
PHI is maintained in the record. We
may deny your access to PHI under certain circumstances, but in some cases you
may have this decision reviewed. On
your request, we will discuss with you the details of the request and denial
process.
·
Right to Amend
– You have the right to request an amendment of PHI for as long as the PHI is
maintained in the record. We may deny
your request. On your request, we
will discuss with you the details of the amendment process.
·
Right to an Accounting
– You generally have the right to receive an accounting of disclosures of PHI.
On your request, we will discuss with you the details of the accounting
process. Accounting requests may not be
made for periods in excess of six years.
·
Right to a Paper Copy
– You have the right to obtain a paper copy of the notice from us upon request,
even if you have agreed to receive the notice electronically.
Therapist’s Duties:
·
We are required by law to maintain the privacy of PHI and to provide you with a
notice of our legal duties and privacy practices with respect to PHI.
·
We reserve the right to change the privacy policies and practices described in
this notice. Unless we notify you
of such changes, however, we are required to abide by the terms currently in
effect.
·
If we revise our policies and procedures, we will inform you with a revised
notice at your next appointment.
If you are concerned that we have violated your privacy rights, or you disagree
with a decision we made about access to your records, you may contact us at our
office and a review will be arranged.
You may also send a written complaint to the Secretary of the U.S. Department of
Health and Human Services. We can
provide you with the appropriate address upon request.
This notice will go into effect on February 8, 2004
810-227-6218
810-227-6982 (fax)