HIPAA Notice of Privacy Practices
As required by the Privacy Regulations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Should you have any questions, please contact us via email at firstname.lastname@example.org. Please review this notice carefully.
Our Commitment to Your Privacy_______
Renewal Center is dedicated to maintaining the privacy of your Protected Health Information (PHI) in our mental health records. In conducting our business, we will create records regarding you and the treatment and the services we provide to you. We are required by law to provide you with this notice or our legal duties and the privacy practices that we maintain in our office concerning your PHI. Any revisions to this notice will be posted in a visible location in our offices.
If you have any questions about this notice, please contact:
Michelle Briggs, Privacy Officer
100 NB Gratiot Ave.
Mt. Clemens, MI 48043
How We May Use Your Individual Health Protected Information (PHI)_______
Treatment: Our practice may use your PHI to treat you. For example, we may use your PHI to coordinate health care with your doctor or hospital in case of emergency or internally for clinical supervision purposes.
Payment: We may use and disclose information to your insurance company if you have asked us to bill for third-party reimbursement.
Releases: When you have signed a written release, we may contact the designee without your direct knowledge until the date that release expires. You have the right, though, to change your mind at any point and revoke the release.
Appointment Coordination: Renewal Center may use your PHI to contact you to remind you of an appointment or to reschedule appointment times. For example, we use your phone number and/or email to send you appointment reminders.
Special Circumstance of Disclosure_______
Public Health Risk: Renewal Center may disclose your PHI to public health authorities that are authorized by law to collect information for the purpose of:
- reporting child abuse or neglect
- preventing or controlling injury or disability
- reporting reactions to drugs or problems with products or devices
- notifying appropriate government agencies and authorities regarding the potential abuse or neglect of an adult (including domestic violence); however, we only disclose if the client agrees or we are required by law.
Lawsuits and Similar Proceedings: Renewal Center may use and disclose your PHI if a response to a court order is mandated. We also may have to disclose your PHI in response to a subpoena or a discovery request.
Law Enforcement: We may release PHI if asked to do so by law enforcement officials:
- regarding a crime victim in certain situations if we are unable to obtain the person's agreement
- concerning a death we believe has resulted from criminal conduct
- regarding criminal conduct at our offices
- in response to a warrant, summons, court order or subpoena
- to identify/locate a suspect, material witness, fugitive or missing person
- in an emergency to report a crime (including the location of victims of a crime, identity, or location of a perpetrator).
Your Rights Regarding Your PHI_______
Confidential Communications: You have the right to request that we communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home rather than work. Please ask your clinician to specify your request.
Requesting Restrictions: You have the right to request a restriction in our use or disclosure of your PHI. We are not required to agree, but if we do then we are bound to our agreement. Talk to our Privacy Officer, Michelle Briggs at (586) 783-2950 if there is information that you wish to be restricted then we are bound to our agreement.
Inspection of Copies: You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you, including patient records and billing records, but not psychotherapy notes. Contact our Privacy Officer for copies of your records. In limited situations, this request may be denied, if this is not in your best interest as decided by your doctor and/or clinician. Mediation from another health care professional will be made available in this case if requested.
Right To Amend: You may ask us to change your records if you feel that there is a mistake. We can deny your request for certain reasons, but we must give you a written reason for our denial.
You Have The Right To An "Account Of Disclosures": You may ask for a list of all disclosures that were made after April 14, 2003. The list will not include the times that information was disclosed regarding treatment, payment, health care operations, or information given to you or others by your own authorization.
You Have The Right To File A Complaint: If you believe that your privacy rights have been violated, you may file a complaint with our privacy officer Michelle Briggs (586) 783-2950 or with the Department of Health and Human Services at (800) 368-1019.