MICHIGAN NOTICE FORM

NOTICE OF PSYCHOLOGIST'S POLICIES AND PRACTICES TO PROTECT THE PRIVACY OF CLIENT'S HEALTH INFORMATION

The law now requires that you receive and acknowledge NOTICE of your rights regarding Protected Health Information (PHI). This notice describes how psychological information about you may be used and disclosed and your rights regarding this information. Please review it carefully.

1. I may need your consent to Use or Disclose your Protected Health Information (PHI) for Treatment, Payment, and/or Health Care Operation. To help clarify these terms, here are some definitions:

Consent requires a signed Release-of-Information Form.

Use applies only to activities within my office such as sharing, employing, applying, utilizing, examining, and analyzing INFORMATION THAT IDENITFIES YOU.

Disclosure apples to activities outside my office such as releasing, transferring, or providing access to information about you to other parties.

Protected Health Information (PHI) refers to information in your health record that COULD IDENTIFY YOU.

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 a session in my office. Coordination would be if I consult with your family physician.

Payment is when I obtain reimbursement for your healthcare. Examples of payment are when I disclose your PHI to your insurance company to obtain reimbursement for your care or to determine eligibility or coverage.

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.

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2. 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. I will also need to obtain an authorization before releasing your Psychotherapy Notes. "Psychotherapy Notes" are notes I have made about our conversation during private, group, joint, or a 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 authorization of PHI or Psychotherapy Notes at any time, provided such 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 for obtaining insurance coverage. Law provides the insurer the right to contest the claim under the policy.

3. USES AND DISCLOSURES WITH NEITHER CONSENT NOR AUTHORIZATION

I may use or disclose PHI without your consent or authorization in the following circumstances:

a. 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.

b. 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.

c. 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.

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d. 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 are being evaluated by a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.

e. 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.

f. Worker's compensation- I may disclose PHI 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.

4. PATIENTS' RIGHTS AND PSYCHOLOGIST'S DUTIES

a. You have the right to request restrictions on certain uses and disclosures of PHI. However, I am not required to agree to a restriction you request.

b. 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.)

c. 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.

d. 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.

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e. 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.

f. 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.

Psychologist's Duties

a. 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.

b. I reserve the right to change the privacy policies and practices of this notice and to make the new notice provisions effective for all PHI that I maintain described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect.

c. If I revise my policies and procedures, I will notify you in person or by first class mail.

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 at 231-796 8881.

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 Totten Psychological Services, 211 Maple, Big Rapids, MI, 49307.

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services, Office of Civil Rights, 200 Independence Ave., S.W., Washington, D.C. 20201.

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

EFFECTIVE DATE, RESTRICTIONS, AND CHANGES TO PRIVACY POLICY

This notice will go into effect on April 14, 2003