Privacy Policy

PLEASE REVIEW THE FOLLOWING NOTICE OF PRIVACY PRACTICES CAREFULLY, AS THIS PRIVACY NOTICE IS REQUIRED TO BE GIVEN TO YOU BY THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) of 1996. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

------NOTICE------

TREATMENT AND PAYMENT:

The Rochester Center for Behavioral Medicine may, in whole or part, use or disclose your protected health information for various reasons without your consent or authorization. (Note: Your health care information relates to your past, present or future physical or mental health condition). For example, and not limited to, consulting a primary care physician or calling prescription orders to a pharmacy. The Rochester Center for Behavioral Medicine will use your protected health information to contact your health insurance provider for coverage confirmation and reimbursement for provided treatment. You have the right to have access to this information and object to uses and disclosures of your protected health care information.

NOTE: The Rochester Center for Behavioral Medicine uses a private medical biller for reimbursement purposes and filing claims, The Rochester Center for Behavioral Medicine's medical biller is entirely compliant with the HIPPA electronic transaction regulation requirements. The Rochester Center for Behavioral Medicine's medical biller will use your protected health information to obtain payment for the services provided to you while you were on the premises, this includes communication with your insurance carrier for approval of treatment provided.

HEALTH CARE OPERATIONS:

The "Health Care Operations" of The Rochester Center for Behavioral Medicine, relates to your protected health care information in that it may be used or disclosed to assist the function of The Rochester Center for Behavioral Medicine. They may be used or disclosed for some or all of the following:

• Administrative activities/ Business management
• Medical reviews, legal services, auditing and/or reviews of compliance
• Training of students, employees or practitioners involved in the health care field
• Employee reviews
• Quality improvement
• Credentialing, accreditation, licensing or certification

The Rochester Center for Behavioral Medicine may also use or disclose your protected health information to: --Contact you to cancel, reschedule or remind you of an appointment. This includes (and not necessarily in this order): Using the phone number(s) that you have provided to The Rochester Center for Behavioral Medicine to contact you. Using our practice name to identify ourselves as the caller. Asking for you specifically by first and last name and, in the event that you are not available to receive our call, we will leave a message with the recipient of our phone call or on an answering service device. The nature of your appointment with The Rochester Center for Behavioral Medicine will be kept in strictest confidence. If you have a specific request regarding how we may contact you, please submit a written request to The Rochester Center for Behavioral Medicine. This request must include the following: The phone number(s) where you wish to be contacted in order for us to cancel, reschedule or remind you of an appointment.

WITHOUT YOUR CONSENT OR AUTHORIZATION:

There are some instances where The Rochester Center for Behavioral Medicine may be required, by the Federal Policy Rules law, to use or disclose your protected health care information beyond treatment, operations or payment, without your authorization or objection. They are as follows:

(1) When legally required, by Federal, State or local laws The Rochester Center for Behavioral Medicine will use or disclose your protected health care information

(2) To report abuse or neglect. This includes, with great respect to professional judgment, that either you have been the victim of abuse or neglect or that you have perpetrated abuse or neglect of another person or persons

(3) For criminal investigations, audits, inspections

(4) When there is a risk to the public such as:

• Notification of a person who has been exposed to a communicable disease
• To report disease (in order to prevent or control it as permitted by law)

(5) The Rochester Center for Behavioral Medicine may be required to use or disclose your protected health care information to a law enforcement official:

• To report a crime. This includes, with great consideration to professional judgment, that you either have recently been the victim of a crime or have carried out activities that would deem in necessary to summons the attention, intervention, assistance or evaluation of a law enforcement official
• To pursue court orders (summons, warrant, subpoena)
• To report physical injuries. This includes, with great respect to professional judgment, that you have sustained physical injuries that require the attention, intervention, assistance or evaluation of a professionally trained medical personnel
• To identify a missing person or a suspect. This includes, with great respect to professional judgment, that you have either been reported as a missing person or are suspected to be involved in a case where another person has been reported as missing

(6) The Rochester Center for Behavioral Medicine may also use or disclose your protected health information in the event that we believe your health or safety or that of the public is in jeopardy

(7) The Rochester Center for Behavioral Medicine may also use or disclose your protected health information for worker's compensation issues to comply with the worker's compensation laws.

WHERE YOUR PROTECTED HEALTH CARE INFORMATION CAN BE USED WITHOUT YOUR AUTHORIZATION BUT WHERE YOU MAY OBJECT:

The following are circumstances where The Rochester Center for Behavioral Medicine may use or disclose your protected health information without your authorization but where you may object:

• In the event that The Rochester Center for Behavioral Medicine needs to contact a family member or close friend that is involved in your care in order to: Notify others of your condition if it is harmful to you or others, or your death.

The Rochester Center for Behavioral Medicine will not disclose your protected health information for other reasons not covered in this notice without your written authorization unless otherwise required by law, as stated above, and you have the right to:

• Obtain a paper copy of this notice in addition to the one you may have already received from The Rochester Center for Behavioral Medicine
• A copy of your protected health information. These records will include records your physician and practice uses for making decisions regarding your care and treatment and billing records. These records will not include psychotherapy notes, information for use in a civil, criminal or administrative action or proceeding and/or protected information to which access is prohibited by law. NOTE: if you would like a copy of your protected health information or would like to inspect them, you must submit a written request. The Rochester Center for Behavioral Medicine may charge you a fee for any administrative costs incurred in this process.
• Request a restriction on uses and disclosures of your protected health information. This request must be in writing and specify the information you would like restricted. The Rochester Center for Behavioral Medicine is not required to agree to a restriction that you request and will notify you with a written reason why your request was denied. You may submit a written disagreement regarding your denied request. If the Rochester Center for Behavioral Medicine does agree with your restrictions, The Rochester Center for Behavioral Medicine may violate that agreement if deemed necessary by law.
• Have your protected health information amended by your physician if you feel this information is incomplete or incorrect. This request must be made in writing, specifying the information you request to be amended. This request may be denied by The Rochester Center for Behavioral Medicine and you will be provided with a written reason why your request was denied. You may submit a written disagreement regarding your denied request.
• To receive a notice ("accounting") if your protected health care information is used for other purposes other than treatment, payment, or health care operations.

Your records cannot be inspected or copied by you if The Rochester Center for Behavioral Medicine believes, with great respect to professional judgment, that this inspection or copy may endanger your life or that of another person.

The Rochester Center for Behavioral Medicine is required by law to maintain the privacy of your protected health information and provide you with this "NOTICE OF PRIVACY". The Rochester Center for Behavioral Medicine reserves the right to change the terms of this notice. If this were to occur, you will receive a copy of the revised addition.

In the event that you wish to air a complaint regarding The Rochester Center for Behavioral Medicine and/or your privacy rights in any way, you have the right to do so. Please contact The Rochester Center for Behavioral Medicine's privacy officer at (248) 608-8800.

Thank you for your time in reviewing this Notice of Privacy Practices.

Sincerely,

The Rochester Center for Behavioral Medicine
441 South Livernois, Suite 205
Rochester Hills, MI 48307