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Notice To NorServ Consumers Consumer Confidentiality, Privacy Statement, Rights and Responsibilities We would like to take this opportunity to inform you of your rights and responsibilities while a consumer at the NorServ Group, Ltd. All consumers are scheduled by appointment. As a consumer you are expected to keep the scheduled appointments you have made. If you are not able to keep your appointment for any reason, we ask that you provide us with 24-hour notice. A cancellation fee will be charged without notice. YOUR CONSUMER RIGHTS: The right to be treated with respect and dignity. The right to privacy. No one can receive information about your mental health services without your written consent. The right to refuse service and to be informed of the consequences. The right to information concerning the services provided. The right to request change in your services. If at any time you have a question, concern or complaint regarding services, we encourage you to contact our Clinical Director OR our Program Director OR our Recipient Rights Officer. YOUR CONSUMER RESPONSIBILITIES: To respect and keep your scheduled appointment times. To be involved in the development of your plan of service and to carry out, to the greatest extent possible, the provisions of that service plan. If you are not satisfied with the service you have received, aggrieved consumers have the right to make a complaint to file a recipient rights complaint. Our Recipient Rights Officer is available to you and can explain the process of filing a complaint. Inform your clinician or the receptionist if you want to request contact with the Recipient Rights Officer. CONFIDENTIALITY: We place the highest value on the confidentiality of information that our consumers share with us. Because of our legal and ethical responsibilities regarding this important issue, we want to clarify the limits of confidentiality. EXCEPTIONS TO CONFIDENTIALITY: There are several important instances when confidential information may be released to others: 1) If we have reason to believe that you are abusing or neglecting your children, we are obligated by law to report this to the appropriate state agency. 2) If you communicate intent to harm either yourself or someone else, and we believe your threat to be serious, we are obligated under the law to take whatever actions seem necessary to protect people from harm. This may include divulging information to others and would only be done under unusual circumstances where someone’s life appeared to be in danger. 3) If you are involved in litigation of any kind and inform the court of the services that you received at our agency (making your mental health an issue before the court), you may be waiving your right to keep your records confidential. You may want to consult with your attorney regarding such matters before you disclose that you have waived your rights. 4) If you are utilizing an insurance policy for reimbursement of services: many insurance companies request periodic information. Ask your therapist for additional information. 5) If, in the course of divorce proceedings, the custody of children is in dispute, the Judge may order release of our records to aid in the decision to award custody. In summary, we make every reasonable effort to safeguard the personal information you share. There are, however, certain instances when we may be obligated under law to release such information to others. If you have any questions regarding confidentiality, please discuss them with your clinician. The State of Health Privacy: Michigan Michigan statutorily requires health facilities to have policies allowing patients access to their medical records. The state does not have a general, comprehensive law prohibiting the disclosure of confidential medical information. Rather, these privacy protections are addressed in statutes governing specific entities or medical conditions. Anti-Solicitation Rules: In an effort to curb solicitation of personal injury claims, Michigan statutorily prohibits any person, firm or corporation from selling and buying the identity of a patient or information pertaining to the treatment of a patient. [ Mich. Comp. Laws § 750.410(2).] Treatment information includes information in the files and records of a Restrictions on Disclosure Information in the record of a recipient of mental health services is confidential and is not open to public inspection. [ Mich. Comp. Laws § 330.1748.] The information may be disclosed only as specifically provided for by law. [ Id. ] All disclosures are to be limited to information that is germane to the authorized purpose for which the disclosure was sought. [ Id. ] Confidential information may be disclosed upon the written consent of the mental health services recipient (or his parent or guardian). [ Mich. Comp. Laws § 330.1748(6).] Disclosure without the recipient’s consent is permitted in a number of circumstances, including: pursuant to court orders or subpoenas, unless the information is privileged; to a prosecuting attorney as necessary for participation in a mental health legal proceeding; as necessary for the purpose of outside research, with certain restrictions; and others. [ Mich. Comp. Laws § 330.1748(5), (7) and (8).] A minor 14 years or older may request and receive outpatient mental health services without the consent or knowledge of the minor’s parent, guardian or person on loco parentis. The mental health professional may not inform the minor’s parent, guardian or person in loco parentis of the services rendered without the minor’s consent unless the professional treating the minor determines that there is a compelling need for disclosure and the minor has been notified of the professional’s intent to disclose that information. [ Mich. Comp. Laws § 330.1707.] Substance Abuse: Records of the identity, diagnosis, prognosis, and treatment of an individual maintained in connection with the performance of a licensed substance abuse treatment and rehabilitation service or prevention service are confidential and generally may be disclosed only with the subject’s written consent. [ Mich. Comp. Laws §§ 333.6111 and 333.6112.] This consent may be revoked at any time by giving written notice. [ Mich. Comp. Laws § 333.6112.] Disclosure may be made without the subject’s consent to: medical personnel to the extent necessary to meet a bona fide emergency; to qualified personnel for the purpose of conducting scientific research, financial audits, or program evaluation, but the personnel may not identify individuals in any reports or otherwise disclose an identity in any manner; to a court, but only information as to whether a specific individual is under treatment by an agency; and for court hearings related to the treatment of minors. [ Mich. Comp. Laws § 333.6113.] WE VALUE CONFIDENTIALITY INFORMATION ABOUT CONFIDENTIALITY AND YOUR INSURANCE Many of us have insurance to cover our medical and mental health needs. What many of us are not aware of is the amount of information our insurance company may have the right to request before authorizing services and payment. Information frequently requested includes: Your name and dependents Address Home and work telephone number Place of employment Social security number Diagnosis Previous treatment history Medical history Functioning level Medications Test results Life history Current stress Detail of what is presently occurring in your life Additional information may also be requested by your insurance provider. Before you use your insurance benefits, we encourage you to contact your insurance company regarding the information they may request, because we value your rights as a consumer. Our fees are based on many factors. They allow us to provide quality mental health services and meet an accredited standard. We take pride in our ability to provide this level of service to you. Taking responsibility for your life is valuable. At least as valuable as the car you drive, the food you eat, and the home you live in. If you are paying out-of-pocket for your services, think about what you can afford based on our fee. Whether you schedule twice a week or a couple of times a month, we will work with you to maximize the benefit you receive from your sessions.