Notice of Privacy Protection

Notice of Privacy Protection

Notice of Privacy Protection

Notice of Privacy Protection

Notice of Privacy Protection

Therapy for Change, PLLC
120 E. Liberty, Suite 350 • Ann Arbor, Michigan • 48104 • 734.730.5534

Notice of Psychologist Policies and Practices To Protect the Privacy of Patient 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
Therapy for Change, PLLC may use or disclose your protected 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 is when a provider provides, coordinates, or manages your health care and other services related to your health care. An example of treatment would be consultation with another health care provider, such as your family physician or another psychologist. 

• Payment is obtaining reimbursement for your healthcare. Examples of payments are when your PHI is disclosed to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage. 

•  Heath Care Operations are activities that relate to the performance and operation of any 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 an office, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you. 

• "Disclosure” applies to activities outside of an office, such as releasing, transferring, or providing access to information about you to other parties. 

II. Uses and Disclosures Requiring Authorization
Therapy for Change, PLLC 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 about and beyond the general consent that permits specific disclosures. In those instances when I am asked for information for purposes outside of treatment, payment or health care operations, I will also obtain an authorization form you before releasing this information.  An authorization must be obtained before releasing your Psychotherapy Notes. “Psychotherapy Notes” are notes made about conversation during private, group, joint, or family psychotherapy, which have been kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI and are almost never released. 

You may revoke all such authorization (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. The law provides the insurer the right to contest the claim under the policy. 

III. Uses and Disclosure with Neither Consent nor Authorization
I may use or disclose PHI without your consent or authorization in the following circumstances:

• Child Abuse and Elder Abuse: If I have reasonable cause to suspect child abuse or neglect, or elder abuse or neglect, I am required by law to report this suspicion to the appropriate authorities.

• Adult and Domestic Abuse: If there is 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. I will not release information without your written authorization or a court order. This privilege does not apply when you are being evaluated, or are 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 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 there is an imminent risk that you will inflict serious physical harm on yourself, I may disclose information in order to protect you.  Such disclose may be to law enforcement in order to assist in voluntary or involuntary hospitalization.

• 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.   

IV. Patient’s Rights and Psychologist’s DutiesPatient Rights:
• Right to Request Restriction: You have the right to request restrictions on certain uses and disclosures of protected health information.  However, a health provider is not required to agree to a restriction you request if they cannot perform their professional duties within the law. 

• 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 being seen. On your request, your bills would be sent to another address.)

• Right to Inspect and Copy: You have the right to inspect or obtain a copy of PHI in mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record.  A health provider may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed.  On your request, a health provider 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.  A health provider may deny your request. 

• Right to Accounting: You generally have the right to receive an accounting of disclosure of PHI. 

• 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. • Right to Restrict Disclosure When You Have Paid for Your Care Out-of -Pocket:  You have the right to restrict certain disclosures of your PHI to a health plan when you pay out-of-pocket in full for services.
 
• Right to Be Notified if There is a Breach of Your Unsecured PHI: You have a right to be notified if: (a) there is a breach causing disclosure of your PHI in violation of the HIPPA Privacy Rule involving your PHI; (b) Your PHI has not been encrypted to government standards; or (c) Risk assessment fails to determine that there is a low probability that your PHI has been compromised. 

Psychologist’s Duties:
• I am required by law to maintain the privacy of PHI and to provide you with a notice of 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 you with any revised notice in writing and you will be asked to sign a form indicating that you have seen and agree to abide to the changes 

V. Questions and Complaints
If you have questions about this notice, disagree with a decision I make about your access to your records or have concerns about your privacy rights you may let me know. If you believe that your privacy rights have been violated and wish to file a complaint with me, you may send you written complaint to me at the above address.  You may also send a written complain to the Secretary of the U.S. Department of Health and Human Services. Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775 or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.  You have specific rights under the Privacy Rule. I will not retaliate against you for exercising your right to file a complaint. 

Effective date of this notice: April 14, 2003, revised December 12, 2016

Therapy for Change, PLLC
120 E. Liberty, Suite 350 • Ann Arbor, Michigan • 48104 • 734.730.5534
 
Notice of Psychologist Policies and Practices
To Protect the Privacy of Patient 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
Therapy for Change, PLLC may use or disclose your protected 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 is when a provider provides, coordinates, or manages your health care and other services related to your health care. An example of treatment would be consultation with another health care provider, such as your family physician or another psychologist.
 
• Payment is obtaining reimbursement for your healthcare. Examples of payments are when your PHI is disclosed to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
 
•  Heath Care Operations are activities that relate to the performance and operation of any 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 an office, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
 
• "Disclosure” applies to activities outside of an office, such as releasing, transferring, or providing access to information about you to other parties.
 
II. Uses and Disclosures Requiring Authorization
Therapy for Change, PLLC 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 about and beyond the general consent that permits specific disclosures. In those instances when I am asked for information for purposes outside of treatment, payment or health care operations, I will also obtain an authorization form you before releasing this information.  An authorization must be obtained before releasing your Psychotherapy Notes. “Psychotherapy Notes” are notes made about conversation during private, group, joint, or family psychotherapy, which have been kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI and are almost never released.
 
You may revoke all such authorization (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. The law provides the insurer the right to contest the claim under the policy.
 
III. Uses and Disclosure with Neither Consent nor Authorization
I may use or disclose PHI without your consent or authorization in the following circumstances:
 
• Child Abuse and Elder Abuse: If I have reasonable cause to suspect child abuse or neglect, or elder   abuse or neglect, I am required by law to report this suspicion to the appropriate authorities.
 
• Adult and Domestic Abuse: If there is 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.  I will not release information without your written authorization or a court order.  This privilege does not apply when you are being evaluated, or are 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 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 there is an imminent risk that you will inflict serious physical harm on yourself, I may disclose information in order to protect you.  Such disclose may be to law enforcement in order to assist in voluntary or involuntary hospitalization.
 
• 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.  
 
IV. Patient’s Rights and Psychologist’s Duties
Patient Rights:
• Right to Request Restriction:  You have the right to request restrictions on certain uses and disclosures of protected health information.  However, a health provider is not required to agree to a restriction you request if they cannot perform their professional duties within the law.
 
• 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 being seen. On your request, your bills would be sent to another address.)
 
• Right to Inspect and Copy: You have the right to inspect or obtain a copy of PHI in mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record.  A health provider may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed.  On your request, a health provider 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.  A health provider may deny your request.
 
• Right to Accounting: You generally have the right to receive an accounting of disclosure of PHI.
 
• 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.

• Right to Restrict Disclosure When You Have Paid for Your Care Out-of -Pocket:  You have the right to restrict certain disclosures of your PHI to a health plan when you pay out-of-pocket in full for services.
 
• Right to Be Notified if There is a Breach of Your Unsecured PHI: You have a right to be notified if: (a) there is a breach causing disclosure of your PHI in violation of the HIPPA Privacy Rule involving your PHI; (b) Your PHI has not been encrypted to government standards; or (c) Risk assessment fails to determine that there is a low probability that your PHI has been compromised.
 
Psychologist’s Duties:
• I am required by law to maintain the privacy of PHI and to provide you with a notice of 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 you with any revised notice in writing and you will be asked to sign a form indicating that you have seen and agree to abide to the changes
 
V. Questions and Complaints
If you have questions about this notice, disagree with a decision I make about your access to your records or have concerns about your privacy rights you may let me know. If you believe that your privacy rights have been violated and wish to file a complaint with me, you may send you written complaint to me at the above address.  You may also send a written complain to the Secretary of the U.S. Department of Health and Human Services. Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775 or visiting www.hhs.gov/ocr/privacy/hipaa/complaints.  You have specific rights under the Privacy Rule. I will not retaliate against you for exercising your right to file a complaint.
 
Effective date of this notice: April 14, 2003, revised December 12, 2016

Therapy for Change, PLLC
120 E. Liberty, Suite 350 • Ann Arbor, Michigan • 48104 • 734.730.5534
 
Notice of Psychologist Policies and Practices
To Protect the Privacy of Patient 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
Therapy for Change, PLLC may use or disclose your protected 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 is when a provider provides, coordinates, or manages your health care and other services related to your health care. An example of treatment would be consultation with another health care provider, such as your family physician or another psychologist.
 
• Payment is obtaining reimbursement for your healthcare. Examples of payments are when your PHI is disclosed to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
 
•  Heath Care Operations are activities that relate to the performance and operation of any 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 an office, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
 
• "Disclosure” applies to activities outside of an office, such as releasing, transferring, or providing access to information about you to other parties.
 
II. Uses and Disclosures Requiring Authorization
Therapy for Change, PLLC 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 about and beyond the general consent that permits specific disclosures. In those instances when I am asked for information for purposes outside of treatment, payment or health care operations, I will also obtain an authorization form you before releasing this information.  An authorization must be obtained before releasing your Psychotherapy Notes. “Psychotherapy Notes” are notes made about conversation during private, group, joint, or family psychotherapy, which have been kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI and are almost never released.
 
You may revoke all such authorization (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. The law provides the insurer the right to contest the claim under the policy.
 
III. Uses and Disclosure with Neither Consent nor Authorization
I may use or disclose PHI without your consent or authorization in the following circumstances:
 
• Child Abuse and Elder Abuse: If I have reasonable cause to suspect child abuse or neglect, or elder   abuse or neglect, I am required by law to report this suspicion to the appropriate authorities.
 
• Adult and Domestic Abuse: If there is 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.  I will not release information without your written authorization or a court order.  This privilege does not apply when you are being evaluated, or are 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 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 there is an imminent risk that you will inflict serious physical harm on yourself, I may disclose information in order to protect you.  Such disclose may be to law enforcement in order to assist in voluntary or involuntary hospitalization.
 
• 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.  
 
IV. Patient’s Rights and Psychologist’s Duties
Patient Rights:
• Right to Request Restriction:  You have the right to request restrictions on certain uses and disclosures of protected health information.  However, a health provider is not required to agree to a restriction you request if they cannot perform their professional duties within the law.
 
• 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 being seen. On your request, your bills would be sent to another address.)
 
• Right to Inspect and Copy: You have the right to inspect or obtain a copy of PHI in mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record.  A health provider may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed.  On your request, a health provider 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.  A health provider may deny your request.
 
• Right to Accounting: You generally have the right to receive an accounting of disclosure of PHI.
 
• 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.

• Right to Restrict Disclosure When You Have Paid for Your Care Out-of -Pocket:  You have the right to restrict certain disclosures of your PHI to a health plan when you pay out-of-pocket in full for services.
 
• Right to Be Notified if There is a Breach of Your Unsecured PHI: You have a right to be notified if: (a) there is a breach causing disclosure of your PHI in violation of the HIPPA Privacy Rule involving your PHI; (b) Your PHI has not been encrypted to government standards; or (c) Risk assessment fails to determine that there is a low probability that your PHI has been compromised.
 
Psychologist’s Duties:
• I am required by law to maintain the privacy of PHI and to provide you with a notice of 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 you with any revised notice in writing and you will be asked to sign a form indicating that you have seen and agree to abide to the changes
 
V. Questions and Complaints
If you have questions about this notice, disagree with a decision I make about your access to your records or have concerns about your privacy rights you may let me know. If you believe that your privacy rights have been violated and wish to file a complaint with me, you may send you written complaint to me at the above address.  You may also send a written complain to the Secretary of the U.S. Department of Health and Human Services. Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775 or visiting www.hhs.gov/ocr/privacy/hipaa/complaints.  You have specific rights under the Privacy Rule. I will not retaliate against you for exercising your right to file a complaint.
 
Effective date of this notice: April 14, 2003, revised December 12, 2016

Therapy for Change, PLLC
120 E. Liberty, Suite 350 • Ann Arbor, Michigan • 48104 • 734.730.5534
 
Notice of Psychologist Policies and Practices
To Protect the Privacy of Patient 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
Therapy for Change, PLLC may use or disclose your protected 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 is when a provider provides, coordinates, or manages your health care and other services related to your health care. An example of treatment would be consultation with another health care provider, such as your family physician or another psychologist.
 
• Payment is obtaining reimbursement for your healthcare. Examples of payments are when your PHI is disclosed to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
 
•  Heath Care Operations are activities that relate to the performance and operation of any 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 an office, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
 
• "Disclosure” applies to activities outside of an office, such as releasing, transferring, or providing access to information about you to other parties.
 
II. Uses and Disclosures Requiring Authorization
Therapy for Change, PLLC 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 about and beyond the general consent that permits specific disclosures. In those instances when I am asked for information for purposes outside of treatment, payment or health care operations, I will also obtain an authorization form you before releasing this information.  An authorization must be obtained before releasing your Psychotherapy Notes. “Psychotherapy Notes” are notes made about conversation during private, group, joint, or family psychotherapy, which have been kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI and are almost never released.
 
You may revoke all such authorization (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. The law provides the insurer the right to contest the claim under the policy.
 
III. Uses and Disclosure with Neither Consent nor Authorization
I may use or disclose PHI without your consent or authorization in the following circumstances:
 
• Child Abuse and Elder Abuse: If I have reasonable cause to suspect child abuse or neglect, or elder   abuse or neglect, I am required by law to report this suspicion to the appropriate authorities.
 
• Adult and Domestic Abuse: If there is 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.  I will not release information without your written authorization or a court order.  This privilege does not apply when you are being evaluated, or are 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 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 there is an imminent risk that you will inflict serious physical harm on yourself, I may disclose information in order to protect you.  Such disclose may be to law enforcement in order to assist in voluntary or involuntary hospitalization.
 
• 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.  
 
IV. Patient’s Rights and Psychologist’s Duties
Patient Rights:
• Right to Request Restriction:  You have the right to request restrictions on certain uses and disclosures of protected health information.  However, a health provider is not required to agree to a restriction you request if they cannot perform their professional duties within the law.
 
• 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 being seen. On your request, your bills would be sent to another address.)
 
• Right to Inspect and Copy: You have the right to inspect or obtain a copy of PHI in mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record.  A health provider may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed.  On your request, a health provider 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.  A health provider may deny your request.
 
• Right to Accounting: You generally have the right to receive an accounting of disclosure of PHI.
 
• 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.

• Right to Restrict Disclosure When You Have Paid for Your Care Out-of -Pocket:  You have the right to restrict certain disclosures of your PHI to a health plan when you pay out-of-pocket in full for services.
 
• Right to Be Notified if There is a Breach of Your Unsecured PHI: You have a right to be notified if: (a) there is a breach causing disclosure of your PHI in violation of the HIPPA Privacy Rule involving your PHI; (b) Your PHI has not been encrypted to government standards; or (c) Risk assessment fails to determine that there is a low probability that your PHI has been compromised.
 
Psychologist’s Duties:
• I am required by law to maintain the privacy of PHI and to provide you with a notice of 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 you with any revised notice in writing and you will be asked to sign a form indicating that you have seen and agree to abide to the changes
 
V. Questions and Complaints
If you have questions about this notice, disagree with a decision I make about your access to your records or have concerns about your privacy rights you may let me know. If you believe that your privacy rights have been violated and wish to file a complaint with me, you may send you written complaint to me at the above address.  You may also send a written complain to the Secretary of the U.S. Department of Health and Human Services. Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775 or visiting www.hhs.gov/ocr/privacy/hipaa/complaints.  You have specific rights under the Privacy Rule. I will not retaliate against you for exercising your right to file a complaint.
 
Effective date of this notice: April 14, 2003, revised December 12, 2016

Therapy for Change, PLLC
120 E. Liberty, Suite 350 • Ann Arbor, Michigan • 48104 • 734.730.5534
 
Notice of Psychologist Policies and Practices
To Protect the Privacy of Patient 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
Therapy for Change, PLLC may use or disclose your protected 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 is when a provider provides, coordinates, or manages your health care and other services related to your health care. An example of treatment would be consultation with another health care provider, such as your family physician or another psychologist.
 
• Payment is obtaining reimbursement for your healthcare. Examples of payments are when your PHI is disclosed to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
 
•  Heath Care Operations are activities that relate to the performance and operation of any 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 an office, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
 
• "Disclosure” applies to activities outside of an office, such as releasing, transferring, or providing access to information about you to other parties.
 
II. Uses and Disclosures Requiring Authorization
Therapy for Change, PLLC 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 about and beyond the general consent that permits specific disclosures. In those instances when I am asked for information for purposes outside of treatment, payment or health care operations, I will also obtain an authorization form you before releasing this information.  An authorization must be obtained before releasing your Psychotherapy Notes. “Psychotherapy Notes” are notes made about conversation during private, group, joint, or family psychotherapy, which have been kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI and are almost never released.
 
You may revoke all such authorization (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. The law provides the insurer the right to contest the claim under the policy.
 
III. Uses and Disclosure with Neither Consent nor Authorization
I may use or disclose PHI without your consent or authorization in the following circumstances:
 
• Child Abuse and Elder Abuse: If I have reasonable cause to suspect child abuse or neglect, or elder   abuse or neglect, I am required by law to report this suspicion to the appropriate authorities.
 
• Adult and Domestic Abuse: If there is 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.  I will not release information without your written authorization or a court order.  This privilege does not apply when you are being evaluated, or are 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 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 there is an imminent risk that you will inflict serious physical harm on yourself, I may disclose information in order to protect you.  Such disclose may be to law enforcement in order to assist in voluntary or involuntary hospitalization.
 
• 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.  
 
IV. Patient’s Rights and Psychologist’s Duties
Patient Rights:
• Right to Request Restriction:  You have the right to request restrictions on certain uses and disclosures of protected health information.  However, a health provider is not required to agree to a restriction you request if they cannot perform their professional duties within the law.
 
• 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 being seen. On your request, your bills would be sent to another address.)
 
• Right to Inspect and Copy: You have the right to inspect or obtain a copy of PHI in mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record.  A health provider may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed.  On your request, a health provider 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.  A health provider may deny your request.
 
• Right to Accounting: You generally have the right to receive an accounting of disclosure of PHI.
 
• 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.

• Right to Restrict Disclosure When You Have Paid for Your Care Out-of -Pocket:  You have the right to restrict certain disclosures of your PHI to a health plan when you pay out-of-pocket in full for services.
 
• Right to Be Notified if There is a Breach of Your Unsecured PHI: You have a right to be notified if: (a) there is a breach causing disclosure of your PHI in violation of the HIPPA Privacy Rule involving your PHI; (b) Your PHI has not been encrypted to government standards; or (c) Risk assessment fails to determine that there is a low probability that your PHI has been compromised.
 
Psychologist’s Duties:
• I am required by law to maintain the privacy of PHI and to provide you with a notice of 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 you with any revised notice in writing and you will be asked to sign a form indicating that you have seen and agree to abide to the changes
 
V. Questions and Complaints
If you have questions about this notice, disagree with a decision I make about your access to your records or have concerns about your privacy rights you may let me know. If you believe that your privacy rights have been violated and wish to file a complaint with me, you may send you written complaint to me at the above address.  You may also send a written complain to the Secretary of the U.S. Department of Health and Human Services. Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775 or visiting www.hhs.gov/ocr/privacy/hipaa/complaints.  You have specific rights under the Privacy Rule. I will not retaliate against you for exercising your right to file a complaint.
 
Effective date of this notice: April 14, 2003, revised December 12, 2016