WHOLE ME COUNSELING LLC, P.O. BOX 970392, YPSILANTI, MI 48197, (734) 315-2307

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I. MY PLEDGE REGARDING HEALTH INFORMATION:

I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to:

Make sure that protected health information (“PHI”) that identifies you is kept private.

Give you this notice of my legal duties and privacy practices with respect to health information.

Follow the terms of the notice that is currently in effect.

I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website.

II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:

The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.

For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. I may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your person health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition.

Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.

Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:

Psychotherapy Notes. I do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:

a. For my use in treating you.

b. For my use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.

c. For my use in defending myself in legal proceedings instituted by you.

d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.

e. Required by law and the use or disclosure is limited to the requirements of such law.

f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.

g. Required by a coroner who is performing duties authorized by law.

h. Required to help avert a serious threat to the health and safety of others.

Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.

Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my business.

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION. Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:

When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.

For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.

For health oversight activities, including audits and investigations.

For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.

For law enforcement purposes, including reporting crimes occurring on my premises.

To coroners or medical examiners, when such individuals are performing duties authorized by law.

For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.

Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.

For workers' compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI in order to comply with workers' compensation laws.

Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.

V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.

Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.

VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:

The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.

The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.

The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.

The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost based fee for doing so.

The Right to Get a List of the Disclosures I Have Made.You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost based fee for each additional request.

The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.

The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it. You may incur charges.

EFFECTIVE DATE OF THIS NOTICE

This notice went into effect on 01/01/2021

Acknowledgement of Receipt of Privacy Notice

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information.

KNOW YOUR RIGHTS

We are dedicated to providing you with quality services. We also believe that as someone who is receiving services from our program, you should know your rights. You should know how to make a complaint if you believe any of your rights have been violated.

You have the right to know

* How much our services cost, and how much you must pay

*When violation of program rules could lead to your discharge

*All about any drugs that are used in your treatment

Note: The program doesn’t use drugs in treatment

*If you, or information about you, will be used in any research or experiments

You have the right to:

*All civil rights guaranteed by State and federal law

*Suggest changes in our services

*Expect us to look into your complaints

*Help make up your own treatment plan

*Refuse our services and be told what will happen if you do

*Talk with your own doctor or lawyer

*Obtain a copy or summary of your client record unless the program director recommends otherwise

Note: The program has the ethical and legal write to determine release of client records. If client records release requests are refused, the program has determined it is in best interest of client requested are not released.

You have the right to expect that program staff will not:

*Abuse and neglect you

*Give out information about you without your permission

*Require you to be part of any research if you don't want to

AND

If you are in a hospital, halfway house, or other live in setting, you have some additional rights.

All of these rights have some special limits. Check with your program rights advisor for further details. These additional rights include the right to:

*Know all the rules about having visitors

*Not be restrained- physically or by drugs, unless authorized by a physician

*Refuse to do work for us unless the work is part of your treatment plan

*Keep your own money

Note: Any and all copayments and balances are expected at time of service if prior arrangements have not been made.

Credit cards on file will be charged for outstanding balances and copayments.

You may incur charges for declined payments.

YOUR RESPONSIBILITIES

Your responsibilities:

* You are responsible for payment of your bill

*You are responsible for knowing if your insurance company will pay for part or all of your bill

*You are responsible for providing clear and accurate information about yourself

*You are responsible for following rules of our program

*You are responsible for being considerate of the rights of others who are recipients of services or our staff

WHAT YOU CAN DO

You and your rights advisor:

If you think your rights have been violated at our program, please talk to your rights advisor. This person is interested in listening to your complaint and helping you find a solution.

Your rights advisor is: Ieeia Currie, LMSW-C 734-635-6522; ieeia@wholemecounseling.com

Please contact your rights advisor if you believe your rights have been violated.

What you can do:

* Talk to your program rights advisor. Maybe together you can find a simple solution to your complaint.

* If that doesn't work, you can fill out a formal complaint. Your rights advisor has complaint forms.

*After you give your complaint to your rights advisor, the complaint will be investigated. You will get a written answer to your complaint within 30 working days.

*If you don't accept the written answer to your complaint, you have 15 working days to file an appeal to the regional rights consultant. Your rights advisor will provide you with appeal forms or you can send for one by writing to MCOSA 22550 Hall Rd Clinton Twp, MI 48036

Within 30 working days, the regional rights consultant will give you a written answer to your appeal.

If you don't agree with the written answer to your appeal, you can file another appeal to the states rights coordinator.

WHO YOU CAN CONTACT IF NEEDED

Your Program Rights Advisor is

Ieeia Currie, LMSW-C

734-635-8655

ieeia@wholemecounseling.com

For additional information or to obtain forms to initiate a complaint contact your local Substance Abuse Coordinating Agency at:

Michigan: Dan Dedloff 530 W. Ionia, Suite F (517) 657-3011 Lansing, MI 48933 dan.dedloff@midstatehealthnetwork.org

Indiana: Jean Gowns (F); Katie Grause (I) (317) 488-5071 INXIXRegion1@gainwelltechnologies.com

Iowa: Rob Aiken, Community Systems Consultant Iowa Department of Human Services Division of Mental Health and Disability Services

Bureau of Community Services & Planning, 1305 E. Walnut Street, 5th Floor SE Cell Phone: 515-669-8002 Fax: 515-564-4166 Email: raiken@dhs.state.ia.us

North Carolina: Council on Developmental Disabilities (NCCDD) 820 South Boylan Avenue, Raleigh, NC 27603 800-357-6916 (v/tty)

919-527-6500 (v/tty) https://nccdd.org

Ohio: Aman Mehra Rhodes State Office Tower, 30 E. Broad Street, 4th Floor, Columbus, OH 43215-3414 (614)466-5928 TTY: (614) 753-2391

Rhode Island: Office of Mental Health Advocate (401) 462-2003

South Carolina: SCDMH Office of Client Advocacy, P.O. Box 485 Columbia, S.C. 29202 1-866-300-9330

Tennessee: Office of Consumer Affairs & Advocacy TN Dept of Mental Health & Substance Abuse Andrew Jackson Bldg 500 Deaderick Street, 5th Floor Nashville, TN 37243 (615) 532-6700 or 800-560-5767

Recipient Rights Websites:

MI: https://www.michigan.gov/-/media/Project/Websites/mdhhs/Folder3/Folder79/Folder2/Folder179/Folder1/Folder279/RR_Book_English.pdf?rev=c7a4164bec73423a843f97183a08faa0

IN: https://www.michigan.gov/-/media/Project/Websites/mdhhs/Folder3/Folder79/Folder2/Folder179/Folder1/Folder279/RR_Book_English.pdf?rev=c7a4164bec73423a843f97183a08faa0

IA: https://www.legis.iowa.gov/docs/ico/chapter/229.pdf

NC: https://files.nc.gov/ncdhhs/LME%3AMCO%20Complaint%20Reporting%20Manual.pdf

OH: https://mha.ohio.gov/get-help/client-rights/ohio-law

RI: http://webserver.rilin.state.ri.us/Statutes/TITLE40.1/40.1-5/40.1-5-26.HTM

SC: https://www.scstatehouse.gov/code/t44c022.php

TN: https://casetext.com/regulation/tennessee-administrative-code/title-0940-mental-health-and-substance-abuse-services/subtitle-0940-05-licensure/chapter-0940-05-38-minimum-program-requirements-for-personal-support-services-agencies/section-0940-05-38-10-service-recipient-rights

It is the intent of Whole Me Counseling PLLC to provide services in an equitable manner and with full respect of all due rights of its service consumers. There may be times, however, when a consumer feels they has been responded to in a way which denies or violates their rights as a client. When this occurs, the agency seeks to address the complaint or grievance in a responsive and impartial manner and to strive for a fair resolution. Following are the agency's procedure for addressing client grievances:

A. At any time that a client feels aggrieved (that is, that their rights as a client have been denied or violated) they are encouraged to:

Make this complaint known to the Practice Client Rights Officer in writing. This person is responsible to assist the person in filing a grievance, to investigate the grievance on behalf of the griever, and to represent the griever at the agency hearing on the grievance, if desired by the griever. The grievance must be dated / signed by the client or individual filing the grievance on behalf of the client. The person should communicate to the client that the action will not result in retaliation or barriers to services.

Client Rights Officer: Ieeia Currie, LMSW-C 734-635-8655; ieeia@wholemecounseling.com

If the Client Rights Officer is unavailable or is the subject of the grievance, the alternative person designated to assist the client with their grievance is: Washtenaw Community Mental Health

B. ALL AGENCY WORKFORCE have a continuing responsibility to immediately advise any client or other person who is expressing a concern, compliant, or grievance of the availability of the client right's officer and the complainant's right to file a grievance. All reasonable effort will be made to provide persons with prompt access to the client rights officer.

C. TIMELINES

1. A client may file a grievance at any time regardless of how long removed from the occurrence of the actions which caused the grievance. However, clients are encouraged to make grievances known as promptly as possible as this will lead to a higher probability of satisfactory investigation and resolution.

2. Once a grievance has been brought to the attention of the client rights officer and has been filed, the time frame for the client rights officer and the agency to process the grievance to resolution shall not exceed (30) thirty working days from the date of filing the grievance. Any extenuating circumstances indicating need for extension will be documented in file and written notification given to the client.

GRIEVANCE PROCEDURE FLOW:

1. Client formulates complaint into a grievance which is received and logged in writing by the client rights officer. The grievance must include the date, approximate time and description of incident and names of individuals involved.

2. Written acknowledgment of receipt of grievance is provided to each grievant within three (3) working days and includes; (a) date grievance received. (b) summary of grievance. (c) overview of investigation process. (d) time table for investigation/notification of resolution. (e) treatment provider contact name/ address/ phone number.

3. Client Rights Officer investigates the grievance, gathers facts, speaks with all parties involved, and attempts effect resolution satisfactory to the griever. If resolved, a written statement of results is given to client.

Whole Me Counseling will seek assistance from supervisors and community mental health professionals to aid in investigation process remaining unbiased. This support will aid in ensuring the client rights officer takes all steps necessary to process client grievances and to otherwise assure compliance with the grievance procedure.

5. If the griever remains unsatisfied, or at an earlier step in the Process, they may initiate complaint with any of several outside entities.

E. POSTING AND DISTRIBUTION

This procedure shall be provided to all consumer/clients.

F. RECORD KEEPING AND REPORTING

1. While investigating grievances, the client rights officer shall record pertinent information which clarifies actions, events, and facts; and which presents the opinions or observations of those involved. This information shall be maintained with the grievance and protected as client confidential information.

2. The clients’ rights officer shall keep records of each grievance received, the subject matter of the grievance, and the resolution. These records shall be available for review by the local Mental Health & Recovery Services Board and the Michigan Department of Mental Health and Addiction Services upon request. Your signature may not be required for Michigan Department of Mental Health and Addiction Services to review.

3. The client rights officer shall annually prepare a report summarizing the number of grievances received, type of grievance, and resolution status.

WHOLE ME COUNSELING LLC, P.O. BOX 970392, YPSILANTI, MI 48197, (734) 315-2307

PRACTICE POLICIES

APPOINTMENTS AND CANCELLATIONS

Please remember to cancel or reschedule 24 hours in advance. You will be responsible for the entire fee of 1$75.00 if cancellation is less than 24 hours.

The standard meeting time for psychotherapy is 53 minutes. It is up to you, however, to determine the length of time of your sessions. Requests to change the 53-minute session needs to be discussed with the therapist in order for time to be scheduled in advance.

A $10.00 service charge will be charged for any checks returned for any reason for special handling.

If I have a deductible, I understand I will be responsible of the full session fee ($275.00 initial session; $210.00 each 53-minute consecutive session), to be paid at each session until my deductible is met.

Cancellations and re-scheduled session will be subject to a full charge if NOT RECEIVED AT LEAST 24 HOURS IN ADVANCE. This is necessary because a time commitment is made to you and is held exclusively for you. If you are late for a session, you may lose some of that session time.

TELEPHONE ACCESSIBILITY

If you need to contact me between sessions, please leave a message on my voice mail. I am often not immediately available; however, I will attempt to return your call within 24-72 hours. Please note that Face- to-face sessions are highly preferable to phone sessions. However, in the event that you are, sick or need additional support, phone sessions are available. If a true emergency situation arises, please call 911 or any local emergency room.

SOCIAL MEDIA AND TELECOMMUNICATION

Due to the importance of your confidentiality and the importance of minimizing dual relationships, I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc.). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it.

ELECTRONIC COMMUNICATION

I cannot ensure the confidentiality of any form of communication through electronic media, including text messages. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, I will do so. While I may try to return messages in a timely manner, I cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.

Services by electronic means, including but not limited to telephone communication, the Internet, facsimile machines, and e-mail is considered telemedicine by the State of California. Under the California Telemedicine Act of 1996, telemedicine is broadly defined as the use of information technology to deliver medical services and information from one location to another. If you and your therapist chose to use information technology for some or all of your treatment, you need to understand that: (1) You retain the option to withhold or withdraw consent at any time without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled. (2) All existing confidentiality protections are equally applicable. (3) Your access to all medical information transmitted during a telemedicine consultation is guaranteed, and copies of this information are available for a reasonable fee. (4) Dissemination of any of your identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without your consent. (5) There are potential risks, consequences, and benefits of telemedicine. Potential benefits include, but are not limited to improved communication capabilities, providing convenient access to up-to-date information, consultations, support, reduced costs, improved quality, change in the conditions of practice, improved access to therapy, better continuity of care, and reduction of lost work time and travel costs. Effective therapy is often facilitated when the therapist gathers within a session or a series of sessions, a multitude of observations, information, and experiences about the client. Therapists may make clinical assessments, diagnosis, and interventions based not only on direct verbal or auditory communications, written reports, and third person consultations, but also from direct visual and olfactory observations, information, and experiences. When using information technology in therapy services, potential risks include, but are not limited to the therapist's inability to make visual and olfactory observations of clinically or therapeutically potentially relevant issues such as: your physical condition including deformities, apparent height and weight, body type, attractiveness relative to social and cultural norms or standards, gait and motor coordination, posture, work speed, any noteworthy mannerism or gestures, physical or medical conditions including bruises or injuries, basic grooming and hygiene including appropriateness of dress, eye contact (including any changes in the previously listed issues), sex, chronological and apparent age, ethnicity, facial and body language, and congruence of language and facial or bodily expression. Potential consequences thus include the therapist not being aware of what he or she would consider important information, that you may not recognize as significant to present verbally the therapist.

MINORS

If you are a minor (dependent on your states minor age limit laws and regulations), your parents may be legally entitled to some information about your therapy. I will discuss with you and your parents’ what information is appropriate for them to receive and which issues are more appropriately kept confidential.

TERMINATION

Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. I may terminate treatment after appropriate discussion with you and a termination process if I determine that the psychotherapy is not being effectively used or if you are in default on payment. I will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If therapy is terminated for any reason or you request another therapist, I will provide you with a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another referral source.

Should you fail to schedule an appointment for three consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, I must consider the professional relationship discontinued.

RECORD RETENTION

Whole Me Counseling PLLC retains medical records (PHI, texts, emails may also be considered medical records by some insurance providers and government agencies) as allocated by governing state. Medical records may be requested for an additional fee (please refer to finance policy) if deemed safe and appropriate by the practicing clinician.

LAPSE IN SERVICES, LEGAL PROCEEDINGS AND INCURRED COSTS

If a client has had a lapse in sessions for more than 45 days, the client will be considered a new client if and when services are reinstated ort continued.

If a client has not seen the therapist for more than 14 days and the client is asked or required to participate in court proceedings, the clinician, Ieeia Currie, LMSW, may not be able to provide the best information concerning the client due to the lapse in services.

Whole Me counseling PLLC and its clinician, Ieeia Currie, LMSW, charge a fee to appear in court. Fees are determined by the case, amount of time clinician, Ieeia Currie, will be required to spend in court in the case you are requested to appear in court.

Please understand, if the clinician, Ieeia Currie, LMSW is required to appear in court. She is required ethically and legally to present on factual and truthful information. The clinician will not and cannot appear in a legal (court or otherwise) setting as a friend, favored witness or any other perceived advocate.

Please always consult with your personal attorney before asking the clinician, or suggesting the clinician be requested to appear for any legal matter on your behalf.

Note: Insurance providers do not cover the costs of clinician court appearances. You will be solely responsible for the cost of the clinician, Ieeia Currie, LMSW-C, if ever requested or required, to appear in a legal proceeding of any kind.

OUTSTANDING BLANCES

Balances more than 60 days old will be reported to collection agency and credit reporting agencies.