Please continue reading for important information regarding your rights.
I have the right to revoke this consent for disclosure of protected personal information at any time. I may be requested to put this request in writing. The revocation will not be effective to the extent that action has already been taken in reliance on the consent, or if this consent was obtained as a condition of obtaining insurance coverage and the insurer has the legal right to contest a claim.
I understand that such information can not be disclosed about me without my written informed consent unless otherwise required by law. I understand that information disclosed pursuant to this consent may be subject to re-disclosure by the recipient of the information and no longer protected by privacy laws and Policies.
I understand that the information in my clinical record may contain name, address, phone number, social security number, insurance information, medication records, dates of service with start and stop times, the modalities and frequencies of treatments used, results of clinical tests, and summary information about diagnosis, functional status, the treatment plan, symptoms, prognosis, progress to date. The clinical record may contain psychiatric, substance abuse, and health information. HRA Psychological Services will make every effort to disclose only the minimum amount of information necessary to conduct the activity that is the subject of this consent.
I understand that "psychotherapy notes" are not subject to disclosure with this general consent form. Psychotherapy notes are given a special level of protection under Federal law (HIPAA), and their disclosure requires a separate Authorization
HRA Psychological Services (and each of its employees) makes every effort to secure and protect individually identifiable health information. This consent form was developed to be compliant with all relevant Federal and State of Michigan law regarding the handling of information obtained in the process of receiving psychological services.
HRA Psychological Services maintains policies for the management of protected health information, including a process for handling complaints or concerns regarding possible violations of privacy rights. Anyone at HRA Psychological Services can give me information about my privacy rights, upon request. Anyone at HRA Psychological Services can give me a paper copy of the Federal HIPAA Privacy Rule NOTICE, or I can ask to review HRA policies on privacy with my provider, the clinical director, or the HIPAA privacy officer.
This form is HIPAA compliant.