Information in your medical record such as information about your health status, treatment, or payment for healthcare that can be linked to your identify is referred to as “Protected Health Information,” or, for short, “PHI.” This section describes the following:

• The concepts of confidentiality and privacy as they pertain to your medical record;
• How the information in your medical record is used;
• Your rights as a recipient of services.

State and federal laws require PHI be kept private and confidential. Under most circumstances, PHI can only be released with the written authorization of the client or the client’s legal guardian. If you would like to release your PHI to a third party, you will be required to sign ACW Counseling’s Authorization for Release of Medical Records. Confidentiality is an integral part of a successful therapeutic relationship; therefore, your privacy is of the utmost importance to ACW Counseling and will be maintained unless otherwise required by law (please see “Limits to Confidentiality”).

Use of Information
Your PHI may be used by ACW Counseling for purposes of:

  • Treatment – Treatment is defined as providing, managing, or coordinating your health care and any related services.
  • Payment – Payment is defined as obtaining compensation for the provision of these health care services. Payment can include either disclosure of PHI to a health insurer to determine eligibility/obtain compensation or from you personally (See Benefits of Private Pay to Confidentiality form).
  • Health Care Operations – Health Care Operations are defined as activities relevant to the operation and performance of ACW Counseling.

Limits to Confidentiality
Under certain circumstances, your clinician is required to disclose PHI without your consent or authorization. This includes:

  • Abuse or neglect of vulnerable persons, such as children, elderly, or disabled individuals – If your psychotherapist has reasonable cause to suspect abuse or neglect of any vulnerable person, s/he must report this suspicion to the appropriate authorities as required by law
  • Serious threat to health or safety – If you communicate to your clinician a threat of physical violence against a reasonably identifiable third person and you have the apparent intent and ability to carry out that threat in the foreseeable future, your clinician may disclose relevant PHI and take the reasonable steps permitted by law to prevent the threatened harm from occurring. If your clinician believes that there is an imminent risk that you will inflict serious physical harm on yourself, he/she may disclose information in order to protect you.
  • Health Oversight Activities – In the event that a clinician receives a subpoena or other lawful request from the Department of Health or the Michigan Board of Psychology, your relevant PHI may be disclosed.
  • Public Safety – PHI may be released for the public interest and safety for public health activities, judicial and administrative proceedings, law enforcement purposes, serious threats to public safety, essential government functions, military, and when complying with worker’s compensation laws.
  • Judicial and Administrative Proceeding – While it is ACW Counseling’s policy to first assert your privilege (or right to private communications), this may be superseded by a court order issued by a judge.

Parents or legal guardians of minor clients who are not emancipated may be allowed by law to examine the minor’s treatment records. Clients over the age of 14 may consent to and may control access to information pertaining to their mental health treatment; however, this treatment may not extend beyond 12 sessions or 4 months. The same limits to confidentiality, as described above, apply to minors.

Client’s Rights

  • Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of PHI; however, ACW Counseling is not required to agree to these requests.
  • Right to Inspect and Copy – You have the right to inspect or copy any of your PHI in ACW Counseling’s records for as long as those records are maintained. This request may be denied under certain circumstances though in some cases you may have the right to have this decision reviewed. You must provide this request in writing.
  • Right to a Paper Copy – You have the right to a copy of all intake paperwork upon request. You must provide this request in writing.
  • Right to an Accounting – You generally have the right to review any disclosures of your PHI. You must provide this request in writing.
  • Right to Amend – You have the right to request an amendment to your PHI for as long as it is maintained in ACW Counseling’s records. You may also request the details of the amendment process. You must provide this request in writing.
  • Right to Receive Confidential Communication by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. You must provide this request in writing.

If you are concerned that your clinician has violated your privacy rights, or disagree with a decision s/he has made regarding access to your records, please bring your concerns to your clinician’s attention. Your clinician will get back to you in a timely manner. If the matter cannot be resolved satisfactorily, there are appropriate state and federal agencies that can provide assistance. You may submit complaints regarding any services provided by a representative of ACW Counseling to the following:

415 South Main Street Suite E
Rochester, MI 48307-2077
(248) 453-4064

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By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Brighter Vision harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.