Notice of Policies and Practices to Protect the Privacy of Your Health Information
This notice is required by the federal government under the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights with regard to the use and disclosure of Protected Health Information (PHI) used for the purpose of treatment, payment, and other health care operations. This notice describes how your information may be used and disclosed and how you can access this information. I am required to obtain your signature indicating that you have received this notice. Please note that this required notice details only minimum protections. I have opted to increase protection of your information as described in the last section of this document.
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 general consent to treatment. 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 related services. An example of treatment would be when I consult with another health care provider, such as your family physician or another mental health practitioner. 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 your coverage. Health Care Operations are activities that relate to the performance and operation of my practice. Examples of health care operations are quality improvement activities and business-related matters such as audits and administrative services.
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 your PHI for purposes outside of treatment, payment, or health care operations only with your authorization. An “authorization” is specific written permission. When I am asked for information for purposes outside 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 if they are maintained separately. “Psychotherapy Notes” are notes I may have made about our conversation during a private, group, joint, or family counseling session, which may or may not be kept separate from the rest of your record.
You may revoke, in writing, all such authorizations at any time. You may not revoke an authorization to the extent that (1) I have already 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 a claim for payment.
III. Uses and Disclosures with Neither Consent nor Authorization
I may use or disclose your PHI without your consent or authorization in following circumstances:
Child Abuse – If I, in the performance of my occupational duties, reasonably suspect that a child has suffered harm as a result of child abuse or neglect, I must immediately report the harm to the appropriate authority.
Adult and Domestic Abuse – If I, in the performance of my occupational duties, have reasonable cause to believe that a vulnerable adult suffers from abandonment, exploitation, abuse, neglect, or self-neglect, then I must report that belief to the appropriate authority.
Health Oversight Activities – I may disclose PHI to the Michigan Board of Psychology or the Department of Health in proceedings conducted by the board or the department where the disclosure of confidential communications is necessary to defend against charges before the board or department.
Judicial and Administrative Proceedings – If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and I will not release information without written authorization of you or your legally appointed representative or court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. I will inform you in advance if this is the case.
Serious Threat to Health or Safety – I may disclose PHI where you communicate an immediate threat of serious physical harm to an identifiable victim. If you present an imminent risk of serious harm to yourself, I may disclose information necessary to protect you.
IV. Patient’s Rights and Practitioner’s Duties
Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information. 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, if you do not want a family member to know that you are seeing me.)
Right to Inspect and Copy – You have the right to inspect and/or obtain a copy of PHI in my records for as long as they are retained with limited exceptions. On your request, I will discuss the request process with you. There may be a fee for copying your records.
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 the amendment process with you.
Right to an Accounting – You have the right to receive an accounting of disclosures of PHI that were made without your authorization (those in Section III of this notice). On your request, I will discuss the accounting process with you. There may be a fee for time required to compile this information.
Right to a Paper Copy – You have the right to obtain copy of this notice from me upon request.
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 provide or make the revisions available to you. If you are a current patient, I will provide you with a revised in person or by mail. If you are a former client, not currently receiving services from me, the most current revision of this notice will always be available at my office.
V. Questions and Complaints
If you have questions about this notice, disagree with a decision I make about access to your records, or have other concerns about your privacy rights, please discuss these with me. If you are dissatisfied with the outcome of that discussion, you may choose between two options. First, you can contact another therapist in our clinic who will act as an intermediary. Or, second, you can send a written complaint to the Secretary of the U.S. Department of Health and Human Services; I can provide you with the appropriate address upon request.
Please note that this notice is a minimum standard dictated by state and federal laws. The same laws allow me to further limit the uses or disclosures that I will make without your consent. I have chosen to further protect your confidentiality by requiring specific authorization for any disclosure in section I of this notice unless you choose to provide general consent for those purposes. This does not affect the uses and disclosures in section III of this notice that do not require your consent.
This notice is effective as of August18, 2003. I reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that I maintain.