PRIVACY PRACTICES

Thalia Ferenc, MSW, MA, LMSW

1005 May Street, Charlevoix MI 49720
Phone: (231) 838-2322

THIS NOTICE DESCRIBES HOW MEDICAL/CLINICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

                                              If you have any questions about this notice,
                                             please contact Thalia Ferenc, MSW.

PLEDGE REGARDING MEDICAL/CLINICAL INFORMATION

I understand that medical/clinical information about you and your care with me is personal.  I am committed to protecting this information about you.  I create a record of the care and services you receive while in treatment.  I need this record to provide you with quality care and to comply with certain legal requirements.  All information is protected by the Federal laws of confidentiality and I pledge to protect all clinical and medical information in compliance with these laws.

HOW INFORMATION MAY BE USED

Ø  Individuals Involved in Payment for Your Care.  With your written authorization, I may release information about you to someone who is paying for your care, such as an insurance company or other funding source.

Ø  Public Health Risks.  I may disclose information about you for public health activities. I will only make this disclosure if you agree in writing or when required or authorized by law.  These activities generally include the following:

 

§  To prevent or control disease, injury or disability.

§  To report child abuse or neglect.

§  To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease.

§  To notify the appropriate government authority if I believe another person is at risk for harm, injury or death because of threats made by you.

 

Ø  Lawsuits and Disputes.  If you are involved in a lawsuit or a dispute, I may disclose information about you in response to a court or administrative order, but only if it is signed by a judge.

Ø  Law Enforcement.  I may release information if asked to do so by a law enforcement official in response to a court order signed by a Judge.

Ø  Right to Inspect and Copy.  You have the right to inspect and copy information from your medical/clinical chart that may be used to make decisions about your care. This includes treatment records but does not include psychotherapy notes.  Psychotherapy notes may be discussed with the therapist. 

To inspect and copy information that may be used to make decisions about you, you must submit your request in writing to me.  If you request a copy of the information, I may charge a fee for the costs of copying, mailing or other supplies associated with your request.

 

I may deny your request to inspect and copy in certain very limited circumstances.  If you are denied access to information in your record, I will discuss the reasons for this with you.   

 

 

Ø  Right to Amend.  If you feel that medical/clinical information I have about you is incorrect or incomplete, you may ask me to amend the information.  You have the right to request an amendment for as long as the information is kept by me.

To request an amendment, your request must be made in writing and submitted to me.  In addition, you must provide a reason that supports your request.

 

I may deny your request for an amendment if it is not in writing or does not include a reason to support the request.  In addition I may deny your request if you ask me to amend information that:

 

§  Was not created by me, unless the person or entity that created the information is no longer available to make the amendment.

§  Is not part of the information kept by me.

§  Is not part of the information which you would be permitted to inspect and copy.

§  Is already accurate and complete.

 

If you are denied the amendment, you may discuss your concerns with me.

 

Ø  Right to an Accounting of Disclosures.  You have the right to request an “accounting of disclosures.”  This is a list of the disclosures I made of medical and/or clinical information about you.

To request this list or accounting of disclosures, you must submit your request in writing to Thalia Ferenc, LMSW.  Your request must state a time period which may not be longer than six years and may not include dates before February 26, 2003.  The first list you request within a 12 month period will be free.  For additional lists, I may charge you for the costs of providing the list. 

 

COMPLAINTS

If you believe your privacy or other rights have been violated, please discuss the situation with me first. I will do everything possible to rectify the situation. If you do not feel the issue has been resolved, you may file a complaint with the Secretary of the Michigan Department of Health and Human Services.  You will not be penalized for filing a complaint.

OTHER USES OF MEDICAL AND CLINICAL INFORMATION

Other uses and disclosures of information not covered by this notice or the laws that apply to me will be made only with your written permission.  If you provide me permission to use or disclose information about you, you may revoke that permission, in writing, at any time.  If you revoke your permission, I will no longer use or disclose information about you for the reasons covered by your written authorization.  Please understand that I am unable to take back any disclosures I have already made with your permission, and that I am required to retain records of the care that I provided to you.