HIPAA Privacy Notice
Notice of Privacy Practices Effective Date: June, 2015
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.
What is this Notice and why is it Important? As of April of 2003, a new federal law (“HIPAA”) went into effect. This law requires that health care practitioners create a notice of privacy practices for you to read. This notice tells you how Effective Psych Care, PLLC, will protect your medical information, how this information may be used or disclosed, and describes your rights. If you have any questions about this notice, please contact Effective Psych Care, PLLC.
Understanding Your Health Information: During each appointment, we record clinical information and store it in your chart. Typically, this record includes a description of your symptoms, your recent stressors, your medical problems, a mental status exam, any relevant lab test results, diagnoses, treatment, and a plan for future care. This information, which is often referred to as your medical or health record, serves as a basis for planning your care and treatment.
We may use your health information and share it in order to:
Provide you with clinical care and communicate with other professionals who are treating you. For example, a mental health provider prescribing medication may need to consult with your primary care provider about your overall health.
Run our practice, improve your care, and contact you when necessary.
Bill and get payment from health plans or other entities.
We may be allowed or required to use your information in other ways - usually ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes.
For more information: www.hhs.gov/ocr/privacy/hipaa/understanding/consumer/index.html
Your Health Information Rights: You have the following rights related to your medical record and protected health information:
You can obtain a copy of this notice. You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
You can authorize Effective Psych Care to use your health information. Before we use or disclose your health information, other than as described in this notice, we will obtain your written authorization, which you may revoke at any time to stop future use or disclosure.
You have the right to your health information. You may ask to see or get an electronic or paper copy of your medical record and other health information we have about you. If you would like to see this information, please ask us how to do this. We will provide a copy or a summary of your health information, usually within 30 days of your request. You have the right to receive information about your diagnosis and treatment. We may charge a reasonable, cost-based fee.
You may request that we change your health information. You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. We may say “no” to your request, but we will tell you why in writing within 60 days. You may request confidential communications. You may request that when we communicate with you, we do so in a specific way (for example, you may request we contact you at a certain mail address or phone number). We will make every reasonable effort to agree to your request. You may request an accounting of disclosures. You may request a list of the times we have shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We will provide one accounting a year for free, but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
You may choose someone to act for you. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action. You may ask us to limit what we use or share. You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information. You may file a complaint if you feel your rights were violated. You can complain if you feel we have violated your rights by contacting us. You can file a complaint with the US Department of Health and Human Services for Civil Rights.
Our Responsibilities
We are required by law to protect the privacy of your health information, to provide this notice about our privacy practices, and to abide by the terms of this notice. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We reserve the right to change our policies and procedures for protecting health information. When we make a significant change in how we use or disclose your health information, we will also change this notice. Except for the purposes related to your treatment, to collect payment for our services, to perform necessary business functions, or when otherwise permitted or required by law and as described above, we will not use or disclose your health information without your authorization. You have the right to revoke your authorization at any time. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html
Will we disclose your health information to family and friends? While the new law allows such disclosures without your specific consent (as long as it contributes to your treatment), our office policy is that we will generally not share your clinical information with your family without a signed authorization from you. The exception to this is if a Effective Psych Care employee believes you pose an immediate danger to yourself or someone else—in that case, we will do whatever is necessary, even if that means breaching confidentiality.
For More Information or to Report a Problem: If you have questions, would like additional information, or want to request an updated copy of this notice, you may contact us anytime.
Crisis Management Plan
This plan is an informal agreement between a patient and Effective Psych Care LLC. In the case of an emergency, patients should utilize this plan and/or allow Effective Psych to act on their behalf.
In a mental health crisis, a Effective Psych Care employee may communicate with your emergency contact. In addition, you agree to call a natural support, such as a family member or friend, to help you through the crisis if possible.
Additional support may be obtained by calling crisis hotlines, such as the following:
1-800-SUICIDE (1-800-784-2433)
1-800-273-TALK (1-800-273-8255)
2-1-1 (Human Services Hotline)
1-800-332-4224 (Foundation 2 Crisis Hotline)
If your crisis becomes unmanageable or you or someone else is in imminent risk of harm, please go to the nearest emergency room or dial 911.
Your provider can be reached during their scheduled business hours. Generally, voice messages will be checked once daily during business hours. We will make every attempt to return calls within 24-48 business hours after receipt of a message.
Effective Psych Care, LLC
Office Policies and Treatment Consent
Patient Rights: Patients have the right to accessible, respectful and quality care, regardless of their age, sex, social status, economic status, ability or disability, gender identity, marriage and civil partnership, race, ethnicity, religion or belief, and sexual orientation.
Patients have the right to obtain knowledge of their provider’s credentials, training, competencies, and licensure status. This information can be found on the Kareo Provider Website and licensure can be verified through the Michigan Departmental of Public Health.
Patients have the right to knowledge of alternative services in the community and alternative forms of treatment that are not provided by employees of Effective Psych Care, PLLC.
Patients have the right to make complaints and are responsible for making their complaints known to
Effective Psych Care, PLLC office manager with a written letter describing the concern needing resolved. Your complaints will be given careful consideration and will be received in a respectful manner.
Patients have the right to feel safe and secure in our office. Should you violate the perceived safety and security of employees or other patients, your treatment may be terminated.
Consent to Treatment: Patients have the right to consent to treatment and/or refuse treatment at any time. If the patient does not have the capability to legally consent to services, they have the right to prompt explanation of services. Providers at Effective Psych Care, PLLC will provide treatment that is mutually agreed upon by both the patient (and/or caregivers) and the provider.
For treatment of a minor, consent for services is required from all legal guardians. In rare cases, we will consider providing treatment without the second parent or guardian’s permission if it is proven the guardian does not have any active involvement with the minor in question. A parent or guardian is expected to attend all appointments with a minor.
Patients have the right to complete and appropriate treatment for their diagnosed condition. In cases for which the most comprehensive treatment modalities are not feasible with an Effective Psych Care Provider, an appropriate referral will be offered.
Patients have the right to be informed of the risks and benefits of treatment provided to them. In addition, patients acknowledge that should they choose not to participate in recommended treatment plans, their provider is not responsible for lack of progress towards their goals and reserves the right to terminate treatment.
Effective Psych Care, PLLC providers may choose to terminate or deny services in the event that the patient repeatedly fails to show for appointments or makes multiple last-minute cancellations. Effective Psych Care, PLLC providers may also choose to terminate or deny services in the event that a patient is suspected to taking their medications not as directed, not complying to medication adherence, selling their medications or overtaking their medications. Effective Psych Care, PLLC may also refer care if the provider feels that the patient needs a higher level of care such as CMH, inpatient treatment, rehabilitation, day treatment program or a clinic that integrates full time therapeutic services.
Patients are responsible for attending all scheduled appointments. We will attempt to remind you of your appointments with both phone call, text, and email reminders. Should a patient need to cancel an appointment, we ask for at least a 24-hour notice. If a patient cancels with less than a 24-hour notice or misses an appointment without notifying the clinic, we reserve the right to charge a $60 fee for an initial visit and $40 for a follow up visit. It is important our patients keep appointments for continuity of care, respect for patients waiting for appointment times, and respect for Effective Psych Care, PLLC and its employees. All Patients receiving a controlled substance will be seen at least every 3 months for a medication review.
Confidentiality: Patients should expect that information provided to Effective Psych Care, PLLC will be kept confidential. Patients may request their personal information be shared with others and Effective Psych Care, PLLC will obtain legal permission to do so with a release of information. Patient diagnosis and treatment information will be shared with insurance providers in order to obtain payment for services provided. By signing below, patients acknowledge that we will submit claims on their behalf to insurance companies using HIPAA compliant resources. Should a patient wish to prevent the sharing of information between a provider and their insurance company, they may choose to pay full fee for services and not bill their insurance providers.
Patients’ confidentiality may be broken without patient permission in order to protect children and dependent adults from abuse or neglect or protect an individual or the public from harm. In addition, Effective Psych Care, PLLC
may be ordered by the courts to release information. In such cases, we will attempt to contact the patient to notify them of this order.
Patient information may be discussed between Effective Psych Care, PLLC staff to coordinate care. This information will be communicated in a respectful manner, releasing only information needed for the continuation of care.
Email and Text: Please note that personal email and text security cannot be guaranteed. Our texting and email line is not HIPPA secure and personal information sent via this portal is discouraged. Information shared via email and text should be limited and used at your own risk. You will receive an email and text prior to your appointment, via our HIPAA compliant electronic health record system. By providing us with your email and phone number, you consent to receiving this appointment reminder. Under no circumstances should email or texting be used to communicate with your provider in an emergency.
Children in the Waiting Room: There may be times when you wish to leave a minor child in the waiting room while you are in session with one of our providers. Please note that we are unable to provide supervision for children who are unattended in the waiting room. We are happy to respond to questions or needs of anyone visiting our offices but are not able to provide the supervision necessary for a child who requires this. If your child requires supervision, you are welcome to either bring someone along to attend to them or have them join you for your session. If you have any concerns, please speak to your clinician.
Payment: Patients are responsible for payment of services. Effective Psych Care, LLC accepts many insurances, but patients are ultimately responsible for copays, deductibles, and any fees that are not covered by the insurance plan. If you are unable to pay for services, we will provide you with an appropriate referral. Patients are expected to pay their copays and deductibles at the time of service. We accept cash, checks, or credit card payments. A fee of $25 will be billed in the case of a returned check. All outstanding balances will require a payment prior to being seen by your provider.
Statements will arrive to the email you provided, so please be sure and be on the lookout for statements in your email!
Prescription Refills: Refills for all medications are written at the time of the appointment. Please ensure you attend appointments to receive them. Refills are not considered an emergency. In the infrequent event that you need an urgent refill, your refill request should go through your pharmacy. Please allow a week for a refill request. For all stimulant medication refills, our office requires monthly refill requests one week prior to script being due. All patients receiving controlled substances are also required to subject to random drug screens periodically to receive their refills. If a drug screen is failed, it is the right of the provider to terminate treatment.
Emergencies: Your provider can be reached during their scheduled business hours. Generally, voice messages will be checked once daily during business hours. We will make every attempt to return calls within 24-48 business hours after receipt of a message. Please refer to the Crisis Management Plan handout provided upon intake for suggestions on how to help you manage an emergency/crisis. You may request an additional copy of that document at any time. Please do not reach out via email or text or patient portal chat with urgent requests. PROVIDER MAY NEED TO TERMINATE YOUR TREATMENT FOR SAFETY REASONS OR REFER YOU TO HIGHER LEVEL OF CARE.
If your crisis becomes unmanageable or you or someone else is in imminent risk of harm, please go to the nearest emergency room or dial 911.
INFORMED CONSENT FOR TELEMEDICINE SERVICES
INTRODUCTION
Telemedicine involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. Providers may include primary care practitioners, specialists, and/or sub-specialists. The information may be used for diagnosis, therapy, follow?up and/or education, and may include any of the following:
Patient medical records
Medical images
Live two way audio and video
Output data from medical devices and sound and video files
Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.
EXPECTED BENEFITS
Improved access to medical care by enabling a patient to remain in his/her office (or at a remote site) while the physician obtains test results and consults from healthcare practitioners at distant/other sites.
More efficient medical evaluation and management.
Obtaining expertise of a distant specialist.
POSSIBLE RISKS
As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:
In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician and consultant(s);
Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;
In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reaction or other judgment error.
BY SIGNING THIS FORM, I ATTEST TO AND UNDERSTAND THE FOLLOWING:
I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine which identifies me will be disclosed to researchers or other entities without my consent,
I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment,
I understand that I have the right to inspect all information obtained and recorded in the course of telemedicine interaction, and may receive copies of this information for a reasonable fee,
I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time. (name of Physician) has explained the alternatives to my satisfaction,
I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
I understand that it is my duty to inform Effective Psych Care of electronic interactions regarding my care that I may have with other healthcare providers.
I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
I attest that I am located in the state of Michigan and will be present in the state of Michigan during all telahealth encounters with my provider at Effective Psych Care.
PATIENT CONSENT TO THE USE OF TELEMEDICINE
I have read and understand the information provided above regarding telemedicine, have discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my medical care.
I understand a copy of this form will be available for me to print.
I hereby authorize Effective Psych Care to use telemedicine in the course of my diagnosis and treatment.
SUBOXONE TREATMENT AGREEMENT (Preview)
SUBOXONE (Buprenorphine/Naloxone) Treatment Agreement
1. I understand that SUBOXONE (Buprenorphine/Naloxone is a narcotic drug that can produce a “high”. I know that taking Buprenorphine regularly can lead to physical dependence and that if I abruptly stop taking it, I could experience symptoms of opioid withdrawal.
2. I understand that Suboxone also contains naloxone. Naloxone will counteract any opioid I am taking causing precipitated withdrawal. I understand I must take Suboxone as ordered and follow instructions as outlined.
3. My provider has discussed with me various options for the treatment of my addiction, including non-pharmacological options. They have explained, and I understand, the risks and benefits of Suboxone, including potential side effects. I understand that in order to be a satisfactory candidate for Suboxone I must follow certain safety precautions for the treatment and comply with the treatment schedule prepared for me by my attending physician and/or my substance abuse counselor. Additionally, my attending physician has discussed this agreement with me and explained what is expected of me in the program. I understand the treatment program and have been given information about the program and adequate time to have my questions answered. As a result, I voluntarily consent to the program.
4. I will take Suboxone by placing it under my tongue to dissolve and be absorbed. I will never inject Suboxone or take it intravenously (IV) because IV use could lead to sudden and severe opiate withdrawal.
5. I will not drive a motor vehicle or use power tools or other dangerous machinery while taking Suboxone until my provider has cleared me to do so.
6. I will inform my MAT Provider of all my other doctor and dentist appointments, and any medications (prescription or non-prescription) that I am taking. I will also report any change in my medical history.
7. I understand that it can be dangerous to mix Suboxone with alcohol or other sedatives (such as Valium, Ativan, Xanax, Klonopin, Librium) benzodiazepines- so dangerous that it could result in an accidental overdose, over-sedation, organ failure,
coma or death. I agree to abstain from ALCOHOL and SEDATIVES while I am being treated with Suboxone. I understand this is important for my safety and to assure that another medication is not prescribed which may lead to harmful side effects.
8. I agree to abstain from all drugs, including alcohol, marijuana, and other street drugs. I understand that continued use of drugs can interfere with my attempts at recovering from opioid dependence. I also understand that Buprenorphine (as found in Suboxone) is designed to treat opioid dependence, not addiction to other classes of drugs. Therefore, I will work with the MAT Provider to design an individualized treatment program to assist me in discontinuing the use of other drugs.
9. My medication must be protected from theft or unauthorized use. I understand that Suboxone must be stored safely, and securely where it cannot be taken accidentally by children, pets or be stolen. If my medications are stolen, I will file a report with the police and bring a copy o my next visit. If another person ingests my Suboxone, I will immediately call 911 or Poison Control at 1-800-222-1222. I agree to take full responsibility for the safekeeping of my Buprenorphine. Lost or stolen Buprenorphine will not be refilled before the date it was due to be renewed unless I can give the clinic a copy of the police report of the loss. I understand my physician reserves the right to refuse refills.
10. I agree not to sell, share, or give any of my medication to another person. I understand that such mishandling of my medication is a serious violation of this agreement and will result in my treatment being terminated without recourse for appeal.
11. If I alter or forge a prescription, I understand that my MAT Provider will terminate my care immediately and will inform the pharmacy and legal authorities of this felony act.
12. I agree to participate in a regular program of professional counseling as recommended by the Practice Staff while being treated with Buprenorphine. If my substance abuse counselor is located outside of the clinic, I will provide proof of regular substance abuse therapy attendance (which may be in the form of a note from my substance abuse counselor) at each visit to my attending physician.
13. I agree to receive support from peers as recommended by the MAT clinic staff and agree to invite significant persons in my life to participate in my treatment.
14. I agree that a network of support is an important part of my recovery, and honest communication among people within the network is important for my treatment. I will provide authorization to allow telephone, email, or face-to-face contact between the MAT clinic staff and physicians, therapists, probation or parole officers, the Department of Social Services, and parents to discuss my treatment and progress. I consent to allow the staff of the MAT clinic to provide others with information regarding my medication usage as needed for my treatment or as otherwise permitted or required by law.
15. I understand that buprenorphine can only be prescribed by a specially licensed physician (Buprenorphine provider). I can only get Buprenorphine refills during scheduled office visits with my Buprenorphine provider, and I will not be able to obtain Buprenorphine refills after regular clinic hours or on weekends.
16. I must take my medications as instructed by my Buprenorphine Provider. I cannot change the way I take my medications or adjust the dose until approved by my Buprenorphine Provider.
17. I agree to see my Buprenorphine Provider on a regular basis. The frequency of visits will be up to my Buprenorphine Provider and will be explained to me.
18. If I miss an appointment, or if I need to reschedule an appointment for a later date, I understand that my medications will not be refilled until the time of my next scheduled appointment with a Buprenorphine Provider. I understand that if I miss, or am late to three appointments, and did not call the clinic in advance, providing at least 24-hour notice, I will be dismissed from the Buprenorphine maintenance clinic and I will not be given any refills for my medication I may also be given a lower dose, enough to sustain and avoid withdrawal.
19. I understand my Buprenorphine Provider or designee will monitor my compliance by counting my Buprenorphine tablets. I agree to bring my Buprenorphine medication to each Buprenorphine clinic visit.
20. I understand that I may be asked to bring in my Suboxone medication to be counted at any time and will come into the office within 24 hours of receiving such a request.
21. I understand that my Buprenorphine Provider will monitor my medication compliance by doing urine or blood drug screens at each visit, at my cost. I consent to testing for this purpose and I understand that it is a requirement of my participation in the Buprenorphine clinic. Drug screens will be “supervised”, and a staff person will be required to be present in the restroom with me in order to ensure that the test specimen is coming from my body.
22. I agree to notify the clinic immediately in case of relapse to drug abuse. Relapse to opiate drug abuse can be life-threatening, and an appropriate treatment plan must be developed as soon as possible. I understand the physician should be informed about a relapse before any urine test shows it.
23. My Provider has recommended that I obtain my Buprenorphine from a single pharmacy. IF POSSIBLE.
24. I agree to conduct myself in a courteous manner in the physician’s or clinic’s offices.
25. I agree to pay all office fees for this treatment at the time of my visits. Failure to do so is cause for immediate termination of services.
26. I understand that if I do not uphold this agreement, I will be dismissed from the program.