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
I 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 I provide, coordinate, or manage your health
care and other services related to your health care. An example of treatment
would be when I consult with another health care provider, such as your family
physician or another psychologist.
– Payment is when I obtain reimbursement for your healthcare.
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 my 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 my office such as sharing, employing,
applying, utilizing, examining, and analyzing information
that identifies you.
• “Disclosure” applies to activities outside of my
office, such as releasing, transferring, or providing access to information about
you to other parties.
II. Uses and Disclosures Requiring Authorization
I 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 I am 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, joint, or 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 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) I have already relied upon and acted on that authorization;
or (2) if the authorization was obtained as a condition of obtaining insurance
coverage. The law provides the insurer the right to contest the claim under
III. Uses and Disclosures with Neither Consent
I may use or disclose PHI without your consent or authorization in the following
• Child Abuse – If I have reasonable cause to suspect child
abuse or neglect, I must report this suspicion to the appropriate authorities
as required by law.
• Adult and Domestic Abuse – If I have reasonable cause
to suspect you have been criminally abused, I must report this suspicion to the
appropriate authorities as required by law.
• Health Oversight Activities – If I receive a subpoena
or other lawful request from the Department of Health or the Michigan Board of
Psychology, I must disclose the relevant PHI pursuant to that subpoena or lawful
• 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 information without your written authorization or
a court order. The privilege does not apply when you are being evaluated, where
the evaluation is court ordered. You will be informed in advance if this is the
• 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, I may disclose relevant PHI and take the reasonable steps
permitted by law to prevent the threatened harm from occurring. If I believe
that there is an imminent risk that you will inflict serious physical harm on
yourself, I may disclose information in order to protect you.
• Worker’s Compensation – I 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
• Right to Request Restrictions – You have the right to
request restrictions on certain uses and disclosures of PHI. However, I am 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 me.
On your request, I 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 my mental health and billing records used
to make decisions about you for as long as the PHI is maintained in the record.
I may deny your access to PHI under certain circumstances, but in some cases
you may have this decision reviewed. On your request, I 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. I may deny your request.
On your request, I 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, I 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 this notice from me upon request, even if you have agreed to receive
the notice electronically.
• I am required by law to maintain the privacy of PHI and to provide you
with a notice of my legal duties and privacy practices with respect to PHI.
• I reserve the right to change the privacy policies and practices described
in this notice. Unless I notify you of such changes, however, I am required to
abide by the terms currently in effect.
• If I revise my policies and procedures, I will post a notice in my office
to alert you to the revisions, and will make available to you a copy of the newly
revised policies and procedures.
If you are concerned that I have violated your privacy rights, or you disagree
with a decision I made about access to your records, you may contact me at
my office, 1745 Hamilton Rd Ste 330, Okemos MI 48864, or call me at (517) 282-0679.
You may also send a written complaint to the Bureau of Health Services of
Michigan, Complaint and Allegation Section, P.O. Box 30670, Lansing, MI 48909-8170.
|1745 Hamilton Rd Ste 330 • Okemos, MI 48864 • (517) 282-0679