Privacy Statement

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 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 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 professional counselor.
  • 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.
  • 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 office, sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
• "Disclosure" applies to activities outside of our office, 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, 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 we are asked for information for purposes outside of treatment, payment or 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 confidential notes we may 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, 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 suspect child abuse or neglect, we must report this suspicion to the appropriate authorities as required by law.
• Adult and Domestic Abuse – If we have reasonable cause to suspect you have been criminally abused, we must report this suspicion to the appropriate authorities as required by law.
• Health Oversight Activities – 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 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 we 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 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 to 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 physical 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 the 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.
• Training and Quality Control – To provide the highest quality of clinical care, at times it may b e necessary for your therapist to consult with another clinician within the organization regarding your treatment.  For example, your therapist may discuss your case, without identifiable information, with his or her supervisor (supervisors are bound by the same confidentiality requirements as your therapist) or in our regularly scheduled peer supervision.  When and if these consultations do occur, information that would identify you specifically will not be disclosed.  

When and if your treatment requires psychiatric services, your therapist will communicate with the psychiatrist on staff regarding your concerns.

In situations where emergency intervention is likely or required, your therapist may consult with the on-call therapist regarding your care. The on-call therapist may discuss your situation with a third party such as hospital emergency personnel. These disclosures will be kept to only the minimum information that is necessary to provide care in your particular situation.

IV. Patient’s Rights and Professional Counselor’s Duties
Patient’s Rights:

• Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information. However, we are not required to agree to a restriction you request.
• 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 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. 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.

Psychologist’s Duties:

• 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.I
• 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 notify you of revised policies by mail.

V. Complaints
If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact our Privacy Officer:

• Nancy Grumm
  3355 Eagle Park Dr. NE, Ste. 106
  Grand Rapids MI 49525-7004
  Tel: (616) 956-9601
  Fax: (616) 956-8033

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The person listed above can provide you with an appropriate address upon request.

IV. Effective Date, Restrictions, and Changes to Privacy Practices
This notice will go into effect on April 14, 2003.

We will limit the uses or disclosures that we make as follows: We will not disclose any information without a release of information form signed other than that which is required by law or when in good faith to use or disclose to avert a serious threat to health or safety of a person or the public and such use or disclosure is to a person or persons reasonably able to prevent or lessen the threat (including the target of the threat).

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 post a copy of the current Notice, with the effective date posted on the first page of the Notice. Each time you register for services, a copy of the current Notice in effect will be made available to you upon your request.