Form-D Notice

  • HIPAA NOTICE OF PRIVACY PRACTICES
  • This notice describes how medical/mental health information about you may be used and disclosed and how you can get access to this information. Please review it carefully. This Notice of Privacy Practices is effective April 14, 2003. The Franciscan Life Process Center only releases medical/mental health information in accordance with state and federal laws and the ethics of the counseling profession.
  • Use and Disclosures of protected health information for the purpose of providing services
  • HIPAA allows for the disclosure of your private health information or PHI without your consent for the following reasons: to coordinate with other professionals to bill and collect payment for services to leave message on your answering machine to comply with health oversight agencies (ie. insurance co-audits) HIPAA states that uses and disclosure of your PHI will be made only with your written consent in the following situations: most uses and disclosures of psychotherapy notes uses and disclosures of PHI for marketing purposes uses and disclosures that constitute a sale of PHI However, the FLPC Counseling Services confidentiality policy, in accordance to ethical guidelines of the counseling profession, requires written permission for any disclosure except for reasons required by law (see below). You can withdraw your permission in writing at any time. State of Michigan law requires that the Franciscan Life Process Center disclose your PHI without your consent if: you are a danger to yourself or others you are unable to meet your basic physical needs you disclose a serious and imminent threat of violence by you against another there is reasonable suspicion of abuse or neglect of a minor, elder, or disabled individual
  • Client Rights Pertaining to Your Protected Health Information
  • HIPAA outlines the following as client rights: the right to see and/or obtain copies of your PHI within 30 days of your written request the right to limit the use and disclosure of your PHI the right to request that the FLPC Counseling Services confidentially communicate through a requested method the right to obtain a list of disclosures of your PHI the right to request an update or modification to your PHI if you believe it to be incorrect the right to request a copy of this notice at any time the right to request someone to act for you the right to file a complaint if you feel your rights were violated Individuals will be notified if there is a breach of unsecured PHI in a timely fashion. If you feel your privacy rights were violated, you can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201
  • Changes to the Terms of This Notice
    The Franciscan Life Process Center reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. The revised Notice of Privacy Practices will be available upon request.