MICHIGAN NOTICE FORM
Notice of Therapist’s/Psychiatrist’s Policies and Practices to Protect the
Privacy of Our 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 READ 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”
o 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.
o Payment is when I obtain reimbursement for your health care. 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.
o 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, clinic, practice group, etc.] such
as sharing, employing, applying, utilizing, examining, and analyzing information
that identifies you.
• “Disclosure” applies to activities outside of my [office, clinic, practice group, etc.]
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 outside of
treatment, payment, or health care operations, I will obtain an authorization from you
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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 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
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 of 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 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, 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
law’s 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.
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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 disclosure 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. 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 the notice
from me upon request, even if you have agreed to receive the notice
electronically.
Therapist’s/Psychiatrist’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 inform you in writing either by mail or
at our next appointment.
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 our
Practice Manager at 616-957-9112.
If you believe that your privacy rights have been violated and wish to file a complaint
with me/my office, you may send your written complaint to our Practice Manager at
1000 Parchment Drive, SE, Grand Rapids, MI, 49546.
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You may also contact the Department of Consumer Industry Services – Complaints
Division at 517-373-9196 or send a written complaint to the Secretary of the U.S.
Department of Health and Human Services, 200 Independence Ave., SW, Washington,
D.C., 20201.
You have the specific right under the Privacy Rule. You will not be penalized for filing a
complaint.
VI. Effective Date, Restrictions, and Changes to Privacy Policy
This notice will go into effect on April 14, 2003.
I will limit or deny the accessibility to inspect and/or copy the PHI when, in the exercise
of professional judgment, the access requested is reasonably likely to cause or bring
substantial harm to you, the patient, if access to the PHI were allowed. This is because
technical language can be misinterpreted and/or upsetting to untrained readers. You
may have denial reviewed by a licensed health care professional who is designated by
me who did not participate in the original decision to deny. Both request and denial
should be in writing.
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. I will provide you with a revised notice in
writing either by mail or at our next scheduled appointment.
