Psychology Associates of Grand Rapids, P.C. and Affiliated Therapists and Psychiatrists
Notice of Psychologists' Policies and Practices to Protect the Privacy of Your 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 REVIEW IT CAREFULLY.
I. Uses and Disclosures for Treatment, Payment, and Health Care Operations
We (Psychology Associates of Grand Rapids, P.C.) 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 we provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when we consult with another health care provider, such as your family physician or another psychologist.
o Payment is when we obtain reimbursement for your healthcare. Examples of payment are when we 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 our 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 our practice group such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
* "Disclosure" applies to activities outside of practice group such as releasing, transferring, or providing access to information about you to other parties.
II. Uses and Disclosures Requiring Authorization
We may use or disclose PHI for purposes outside of treatment, payment, and 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 we are asked for information for purposes outside of treatment, payment and health care operations, we will obtain an authorization from you before releasing this information. We will also need to obtain an authorization before releasing your psychotherapy notes. "Psychotherapy notes" are notes we have made about our conversation during a private, group, joint, or family counseling session, which we 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) we have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.
III. Uses and Disclosures with Neither Consent nor Authorization
We may use or disclose PHI without your consent or authorization in the following circumstances:
* Child Abuse: If we have reasonable cause to believe that a child has been subject to abuse, we must report this immediately to the Michigan Division of Youth and Family Services.
* Adult and Domestic Abuse: If we reasonably believe that a vulnerable adult is the subject of abuse, neglect, or exploitation, we may report the information to the county adult protective services provider.
* Health Oversight: If we receive a subpoena or other lawful request from the Department of Health or the Michigan Board of Psychology, we must disclose the relevant PHI pursuant to that subpeona or lawful request.
* Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about the professional services that we have provided you and/or the records thereof, such information is privileged under state law, and we must not release this information without written authorization from you or your legally appointed representative, or a court order. This privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. We must inform you in advance if this is the case.
* Serious Threat to Health or Safety: If you communicate to us 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, we may disclose relevant PHI and take the reasonable steps permitted by law to prevent the threatened harm from occurring. If we believe that there is an imminent risk that you will inflict serious harm on yourself, we may disclose information in order to protect you.
* Worker's Compensation: We 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 Duties
* Right to Request Restrictions -You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, we are 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 us. Upon your request, we 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 our mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. We may choose to provide you with a summary of your record. We may deny your access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. On your request, we 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. We may deny your request. On your request, we 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 for which you have neither provided consent nor authorization (as described in Section III of this Notice). On your request, we 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 us upon request, even if you have agreed to receive the notice electronically.
* We are required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI.
* We reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect.
* If we revise our policies and procedures, we will post such a notice in our offices and give you a copy at your next appointment.
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 Business Manager at 616-957-9112.
If you believe that your privacy rights have been violated and wish to file a complaint with our office, you may send your written complaint to our Business Manager at 1000 Parchment Drive, SE, Grand Rapids, MI, 49546.
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 specific rights under the Privacy Rule. You will not be penalized for filing a complaint.
This notice will go into effect on April 14, 2003.
We will limit or deny the accessibility to inspect and/or copy the PHI when, in the exercise of professional judgement, 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 my denial reviewed by a licensed health care professional who is designated by me and who did not participate in the original decision to deny. Both request and denial should be in writing.
We reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that we maintain. We will provide you with a revised notice by posting in our office and giving you a copy at your next appointment.