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.
1. Uses and Disclosures for Treatment, Payment, and Health Care Operations:
We may make use of 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, Payments and Health Care Operations” refers to:
· 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 I obtain reimbursement for your health care. Examples of payment are when I 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 improvement activities, business related matters such as audits and administrative services, and case management and care coordination.
· “Use” applies only to activities within Counseling and Resource Center of Dearborn such as sharing, employing, utilizing, examining, and analyzing information that identifies you.
· “Disclosure” applies to activities outside of Counseling and Resource Center of Dearborn, such as releasing, transferring, or providing access to information about you to other parties.
2. Uses and Disclosure Requiring Authorization
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, I will obtain an authorization from you before releasing this information. I will also need to obtain an authorization before releasing your “Psychotherapy Notes.” “Psychotherapy Notes” are notes I have made about our conversation during a private, group, or joint family counseling session, which I 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 authorization (of PHI and 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, and other law provides the insurer the right to contest the claim under the policy.
3. Uses and Disclosures with neither Consent nor Authorization
We may disclose PHI without your consent or authorization in the following circumstances:
· Child Abuse—If we have reasonable cause to suspect child or neglect, I 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 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 I will not release your information without your written authorization or a court order. The privilege does not apply when you are being evaluated for a third party or where your 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 me a threat of physical violence against a reasonably identifiable third person and you have 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 harm on yourself, I may disclose information in order to protect you.
· Workers compensation—We may disclose protected health information regarding you as authorized by and to the extent necessary to comply with law as relating to workers compensation or other similar programs, established by law, that provide benefits to work related injuries or illness in regard to fault.
4. Patient’s Rights and Therapist’s Duties:
· Right to Request Restrictions—You have the request restrictions on certain uses and disclosure 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 Alternative Locations—you have the right to request and receive confidential communications of PHI by alternate means and at alternate locations. (For example, you may not want a family member to know that you are being seen here. Per your request, we will send bills to another address.)
· Right to Inspect and Copy—you have the right to inspect or obtain a copy (or both) of PHI in the mental health setting and billing records used to make decisions about 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 the details of the amendment process.
· Right to Paper Copy—You have the right to obtain a paper copy of the notice from me upon request, even if you have agreed to receive the notice electronically.
· We are required by law to maintain the privacy of PHI and to provide you with a notice of legal duties and privacy practices with respect to PHI.
· We reserve the right to change the privacy policies 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 notify you with a written document that we will give you personally. If you are no longer in treatment and your notes are requested, we will mail you the document.
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 any time to inform us of this concern.
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 the Allegations Division of the Department of Consumer and Industry Services (517-373-9196). The website for further information is www.michigan.gov.cis.
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.
Effective date: April 13, 2003.
We reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that we maintain. We will provide you with a revised notice either personally or by mail. In this document, “we” refers to any and all practitioners at Counseling and Resource Center of Dearborn.