Notice of Privacy Practices – Effective April 14, 2003

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 or coordinate services related to your health care, for example if I consult with another health care provider, such as your family physician or another therapist.

• Payment is when I obtain reimbursement for your healthcare, for example when I disclose PHI to your health insurer.

• Health Care Operations are activities that relate to the performance and operation of my practice. Examples of health care operations are quality assessment, audits and administrative services, and case management.

• “Use” applies only to activities within my practice such as using, examining, recording information that identifies you.

• “Disclosure” applies to activities outside of my practice, such as releasing, or providing 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.

“Psychotherapy Notes” are notes I make about our conversation during a private, group, joint, or family counseling session.

These are also notes that I may make for my own use to remind me of matters I wish to discuss with you at a later date. They may be handwritten and in incomplete form. These notes might also include sensitive matters about you or someone else which I wish to remember accurately but which I do not believe are necessary to include in your clinical notes. In mental health treatment Psychotherapy

Notes are given a greater degree of protection than the rest of the PHI. They are kept separate from the rest of your medical record.

Normally they are not available for your review, and they are only disclosed under very special circumstances. Before disclosing them I would need to obtain from you a special authorization which includes a statement of the reason for the disclosure.

You may revoke authorizations of PHI or Psychotherapy Notes at any time, provided each revocation is in writing. You may not revoke an authorization if I have already relied on the authorization and disclosed the record. You also may not revoke an authorization if it was used to obtain insurance coverage if the law provides the insurer the right to contest the claim under the policy.

III. 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 State of Michigan Department of Consumer and Industry Services 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 or a third party is being evaluated and 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.

• National and Homeland Security – I may disclose protected health information as part of an investigation for national security and law enforcement purposes.

IV Client’s Rights and Therapist’s Duties

Client’s Rights:

• 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, 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. If you elect to inspect or copy your PHI I will require that you make the request in writing. I will also ask you to sign a receipt indicating that you have received a copy of your clinical record, and that request and receipt will become part of your PHI. 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. You may then state your request for amendment in writing and have it added to the record. 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 the The Notice (this document) from me upon request, even if you have agreed to receive the notice electronically.

Therapist’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 notify all current clients in writing. I will make a good faith effort to notify former clients in writing if and when they submit an authorization for disclosure or a request for an accounting of disclosure, and a good faith effort will be made to serve this notification at either the client’s last known address or at a new location which is provided along with the disclosure or accounting request.

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 you may contact me about that either in person, by telephone, or by mail at the address and phone number which appears on your Therapist-Client Services Agreement.

If you believe that your privacy rights have been violated and wish to file a complaint you may send your complaint to me in writing. If we are not able to resolve the disagreement, I will provide you with the names of three licensed mental health professionals from which you may select and consult one to mediate the grievance at your expense.

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The address for this office appears in the telephone directory under the section for government offices and agencies. You may also contact me and I will provide you with the appropriate address upon request.

You have specific rights under the Privacy Rule. I will not retaliate against you for exercising your right to file a complaint.

VI. Effective Date, Restrictions, and Changes to Privacy Policy

This notice will go into effect on April 14, 2003. Records dated prior to this effective date will not be subject to the conditions of this notice unless otherwise required by law.

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.

Current client’s will be notified in writing. Former client’s will be notified at their request or upon the receipt of an Authorization or a Request for Accounting.Description text goes here