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Ann Arbor Center for the Family Notice of Privacy Practices Effective April 24, 2003 / Revised December 10, 2004 This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. If you have questions about this Notice please contact our Privacy Officer, Andrew Orosan-Weine, Ph.D. Please request a Notice of Privacy Practices from your Therapist. This Notice of Privacy Practices describes how we may use and disclose your Protected Health Information (PHI) to carry out treatment, payment, or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your Protected Health Information. “Protected Health Information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices by accessing our website , calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment. PURPOSE:Ann Arbor Center for the Family and its Affiliates, employees, and trainees follow the privacy practices described in this Notice. The Center keeps your mental health information in records that will be maintained and protected in a confidential manner, as required by law. Please note that in order to provide you with the best possible care and treatment, all professional staff involved in your treatment and employees involved in the health care operations of the Center may have access to your records. HOW WILL The Ann Arbor Center for the Family USE MY PROTECTED HEALTH INFORMATION? (PHI is information that could identify you, e.g. name, phone number, social security number, etc.) We collect medical information from you. Within the Center, we restrict the disclosure of this information to therapists, psychiatrists, and insurance and billing personnel. Outside the Center, we restrict the disclosure to those people, entities and agencies for whom you authorize disclosure such as other health care providers, insurance companies, billing agencies, hospitals, or those agencies and entities for whom legal and administrative requirements demand disclosure. WHAT ARE TREATMENT and HEALTH CARE OPERATIONS? Your treatment may include sharing information among mental health care providers who are involved in your treatment. For example, if you are seeing both a physician (psychiatrist) and a psychotherapist, they may share information in the process of coordinating your care. In addition, we may disclose your Protected Health Information to another physician or health care provider (e.g., a specialist or laboratory) who, at the request of your therapist, becomes involved in your care by providing assistance with your health care diagnosis or treatment. Examples include: •Appointment reminders or notification that an appointment is canceled or rescheduled by your therapist. • Payment from a third-party insurance company. A bill may be sent to them that may include information that identifies you, as well as your diagnosis and procedures. • Coverage by another mental health professional during vacations. • Information needed by your pharmacy for prescriptions. • Mental health oversight activities, e.g. audits, inspections or investigations of administration and management of the Center. • As required by law. • For public health purposes such as reporting child abuse or elder abuse or neglect. • Lawsuits and disputes. • Law enforcement (e.g., in response to a court order or other legal process). • To prevent a serious threat to health or safety of yourself or others. • To carry out treatment and health care operations functions through medical transcription services. • To authorized federal officials for the conduct of lawful intelligence, counter intelligence, and other national security activities. • Alcohol and drug abuse information has special privacy protection. The Center will not disclose any information identifying an individual as being a client or provide any mental health or medical information relating to a client’s substance abuse treatment unless; 1) the client consents in writing; 2) a court order requires disclosure of the information; 3) medical personnel need the information to meet a medical emergency; 4) it is relevant in reporting a preventing a threat of harm to yourself or others. YOUR AUTHORIZATION IS REQUIRED FOR OTHER DISCLOSURES. Except as described previously, we will not use or disclose information from your record unless you authorize (permit) in writing to do so. You may revoke your permission, which will be effective only after the date of your written revocation. YOU HAVE RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION. You have the following rights regarding your health information, provided that you make a written request to invoke the right on the form provided by the Ann Arbor Center for the Family. • Right to request restriction. You may request limitations on your mental health information we may disclose, but we are not required to agree to your request. If we agree, we will comply with your request unless the information is needed to provide you with emergency treatment. • Right to confidential communications. You may request communications in a certain way or at a certain location, but you must specify how or where you wish to be contacted. • Right to inspect and copy. You have the right to inspect and copy your mental health information regarding decisions about your care; however, psychotherapy notes (notes made by your therapist about your conversations) may not be inspected and copied. We may charge a fee for copying, mailing, and supplies. Under limited circumstances, your request may be denied; you may request review of the denial by another licensed mental health professional chosen by the Ann Arbor Center for the Family. The Center will comply with the outcome of the review. • Right to request clarify record. If you believe the information we have about you is incorrect or incomplete you may ask to add clarifying information. You may ask for a form for that purpose and the form will require certain specific information. The Center is not required to accept the information that you propose. • Right to accounting of disclosures. You may request a list of the disclosures of your mental health information that have been made to persons or entities other than for treatment or health care operations in the last six (6) years, but not prior to April 14, 2003. • Right to a copy of this Notice. You may request a paper copy of this Notice at any time, even if you have been provided with an electronic copy. REQUIREMENTS REGARDING THIS NOTICE. The Ann Arbor Center for the Family is required to provide you with this Notice that governs our privacy practices. The Center may change its policies or procedures in regard to privacy practices. If and when changes occur, the changes will be effective for mental health information we have about you as well as any information we receive in the future. Any time you come in to the Center for an appointment, you may ask for and receive a copy of the Privacy Notice that is in effect at the time. COMPLAINTS. If you believe your privacy rights have been violated, you may file a complaint with the Ann Arbor Center for the Family. You will not be penalized or retaliated against in any way for making a complaint. CONTACT. Call the Ann Arbor Center for the Family and ask to speak to Andrew Orosan-Weine, Ph.D. if:         • You have a complaint.         • You have a question about this notice.         • You wish to request restrictions on uses and disclosure for health care treatment or operations.         • To obtain any of the forms mentioned to exercise the individual rights described above. For more information about HIPAA contact: Office for Civil Rights; US Department of Health & Human Services 233 N. Michigan Ave., Suite 240 Chicago, IL 60601 (312) 886-2359; (312) 353-5693 (TDD) (312) 886-1807 (Fax) Ann Arbor Center for the Family 2300 Washtenaw, Suite 203, Ann Arbor, Michigan 48104 (734) 995-5181 Contact the Center Site Design by Chris Wozniak Pages created and maintained using Arachnophilia