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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.
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 the
policy.
Uses and Disclosures with Neither
Consent nor Authorization
I may
use or disclose PHI without your consent or authorization in the
following circumstances:
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 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
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 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, 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.
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 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.
Psychologist’s Duties
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.
Complaints
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, 999 Haynes, Suite 300 Birmingham, MI
48009 or call me at (248)770-3536.
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. (517)241-2389.
Effective Date, Restrictions, and
Changes to Privacy Policy
This
notice will go into effect on April 14, 2003. If there is a
change to the privacy policy, a new copy will be posted.
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