MICHIGAN NOTICE FORM
Notice of Psychologist’s Policies and Practices to Protect
the Privacy of Your Patient’s Health Information
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.
I. Uses and Disclosures for Treatment, Payment, and Health Care Operations
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 office, such
as sharing, employing, applying, utilizing, examining, and analyzing
information that identifies you.
"Disclosure" applies to activities outside of our office,
such as releasing, transferring, or providing access to information about you
to other parties.
II. Uses and Disclosures 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, 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, law provides the insurer the right to contest the claim under the
policy.
III. Uses and Disclosures with Neither Consent nor Authorization
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 me 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.
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.
IV. Patient’s Rights and Psychologist’s Duties
Patient’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.
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.
Psychologist’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 notify you either in
person or by mail.
V. Complaints
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
this office at 805 W. Maumee Street, Adrian, MI 49221, telephone number (517)
265-8658 and if the situation cannot be resolved, you will be given further
information about how to proceed with your complaint under the laws of the State
of Michigan.
You may also send a written complaint to the Secretary of the U.S. Department
of Health and Human Services. A person listed at the above location can provide
you with the appropriate address upon request.
VI. Effective Date, Restrictions, and Changes to Privacy Policy
This notice will go into effect on April 14, 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 in person by mail and post the revision on our web site at
www.warwick-associates.com where it will be available for download.
Download HIPAA Notice by clicking
here.
