IN•TER•IM ASSOCIATES, PLLC

Your privacy is important:

We care very much about your privacy. Unless you give permission in writing, we will disclose only information for purposes of treatment, payment, business operations, or when required to do so by the law effective April 14, 2003 .

What type of information does Interim Associates collect and why?

We collect information from you and when you give us written releases from other sources. This includes your name, address, date of birth, and other personal information you supply. We also generate data about you for assessment, diagnosis, and treatment, and may generate reports for agencies to whom you authorize such a release of your personal information.

How does Interim Associates use this information?

• Treatment - As authorized by you in your consent agreement and/or with written releases.
• Payment - Communication with your insurance agency or designated organization.
• Business Operations - Communication with affiliated businesses for the purposes of billing, collections, clinical supervision and/or as you have authorized.
• As Required by law - There are various reasons your information may be released including to avert a serious threat to health or safety, military and veterans if required by command authorities, worker’s compensation laws, public health risks, health oversight activities, lawsuits and disputes, court orders, national security and complying with insurance law or administration of claims or quality assurance.
• Exceptions - as granted only by you with your written permission through a specific release of information authorization.

Privacy rights include:

• The right to inspect and copy: In writing you may request a copy of your information. A reasonable fee may be charged for this service.
• The right to amend: In writing, you may ask that we change or add information. We can deny your request for certain reasons, and must give you a written response regarding any denial.
• The right to a list of disclosures: In writing, you have a right to ask for a list of disclosures made with your information to parties other than you. A reasonable fee may be charged for this service.
• The right to request restrictions on uses and disclosures: In writing, you make request that information not be disclosed, or you may request that a release be withdrawn. Some information for business purposes may not be restricted and IA is not required to agree to requests.
• The right to request confidential communications: In writing, you may request communications through alternative means or an alternative location. We reserve the right to not agree to requests.
• Any Changes to this notice: We reserve the right to revise this notice Any revised notice will be effective for medical information we already have about you as well as information we may develop in the future. We are required by law to comply with whatever notice is in effect. Any changes will be published in a new notice.
• How to use your rights under this notice: If you want to use your rights under this notice, you may call us or write to us. If you wish to have help writing a complaint, we will help you if you wish.
• Complaints and Communications To Interim Associates: Privacy Officer Interim Associates, PLLC 806 North Emily St. Ludington , MI 49431 Phone: 231.843.8222
• Email: patrick@interimcounseling.org To the Federal Government: If you believe your privacy rights have been violated, you have the right to file a complaint with the federal government. You may write to: Office of Civil Rights US DHHS 200 Independence Ave. SW Washington DC 20201 You will not be penalized for filing any complaint
• For copies of this notice: You have the right to an another copy of this notice at any time. Please call or write to request a copy. This notice is available in other languages and alternate formats that meet the guidelines for the Americans with Disabilities Act (ADA). <Esta notificacion esta disponible en otras lenguas y formatos diferentes que satisfacen las normas del Acta de Americans with Disabilities (ADA).>

Michigan Mental Health Code Public Act 258, Section 748- Regarding Confidentiality:

• Information in the record of a recipient, and other information acquired in the course of providing mental health services to a recipient, shall be kept confidential and shall not be open to public inspection. The information may be disclosed outside the department, county, community mental health program, or licensed private facility, whichever is the holder of record, only in the circumstances and under the conditions set forth in this section.

1. When information is disclosed, the identity of the individual to whom it pertains shall be protected and shall not be disclosed unless it is germane to the authorized purpose for which disclosure was sought, and, when practicable. No other information shall be disclosed unless it is germane to the purpose for which disclosure was sought.
2. Any person receiving information made confidential by this section shall disclose information to other only to the extent consistent with the authorized purpose for which the information was obtained.
3. When requested, information shall be disclosed: a. Pursuant to orders or subpoenas of a court of record, or subpoenas of the legislature, unless the information is made privileged by some provision of the law. b. To a prosecuting attorney as necessary for him/her to participate in a proceeding governed by this act. c. To an attorney for the recipient, when the recipient has given consent. d. When necessary in order to comply with another provision of the law. e. To the department when the information is necessary in order for the department to, discharge a responsibility upon it by law. f. To the office of the Auditor General when the information is necessary for that office to discharge its responsibility.
4. Information may be disclosed if the holder of the record and the recipient, his [her] parent(s), if he is a minor, or his legally appointed guardian consent: a. To providers of mental health services to the recipient. b. To the recipient of or any other person or agency, provided that, in the judgment of the holder, the disclosure would not be detrimental to the recipient or others.
5. Information may be disclosed at the discretion of the holder of record: a. As necessary in order for the recipient to apply for or receive benefits. b. As necessary for the purpose of outside research, evaluation, accreditation, or statistical compilation, provided that the person who is the subject of the information can be identified from the disclosed order only when such identification is essential in order to achieve the purpose for which the information is sought or when preventing such identification would clearly be impractical, but not in the event when the subject of the information is likely to be harmed by such identification. c. To providers of mental or other health services or a public agency when there is a compelling need for disclosure based upon substantial probability of harm to the recipient or other persons.

As a client receiving therapeutic services you have certain rights which include:

• To respectful treatment free of any sexual, physical or emotional abuse
• A full disclosure of my professional experience and training
• A full disclosure of the terms of therapy including cost, appointment times, procedures and agreements
• Having any therapeutic procedure fully explained including its risks and benefits
• To see any information about you in my files, or to have it shared with another professional
• To ask me anything about therapy, and if not satisfied to make a complaint
• Reporting any illegal or immoral behavior by me.
• To not enter into therapy with me; or to discontinue therapy at any time.
• To refuse any test, evaluation or therapy of any kind.
• To refuse to answer any question, or give any information you choose not to give
• To know if I will discuss your case with anyone else (e.g. with supervisors, consultants etc.)
• Ask that I inform you of your progress
• To ask any question, at any time about what we do during therapy and to receive satisfying answers

This is a very brief summation of Michigan and Federal laws that govern my work. If you wish more information, please ask me or contact the Michigan Department of Community Health - Mental Health Division.