ACKNOWLEDGEMENT OF RECEIPT
OF
I acknowledge that I have received the MMI HIPAA Privacy Notice.
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Printed Name of Person Receiving Services
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Printed Name of Guardian (if one)
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Signature of Guardian or Person Served if Own Guardian Date
PRIVACY NOTICE
We care about your privacy. The information we collect about you is protected by two laws: the Michigan Mental Health Code and the Federal Health Insurance Portability and Accountability Act (HIPAA). We are required to give you a notice of our privacy practices. Only people who have both the need and the legal right may see your information. Unless you give us permission in writing, we will only disclose your information for purpose of treatment, payment, business operations or when we are required by law to do so.
· Treatment MMI may disclose health information about you to coordinate your health care. For example, we may disclose information to other health care providers in our service network, such as your supports coordinator, school professionals or to the staff of a group home in which you reside.
· Payment MMI may use and disclose information so the care you get can be properly billed and paid for. For example, we are required to report to your funding source about the services you receive to obtain payment from them.
· Business Operations MMI may use and disclose information for our business operations. For example, we may use information to review the quality of your services or to report program outcomes.
· As Required by Law We will release information when we are required by law to do so. Examples of such releases would be for law enforcement or national security purposes, subpoenas or other court orders, communicable disease reporting, disaster relief, review of our activities by government agencies, to avert a serious threat to health or safety or in other kinds of emergencies.
· With your Permission If you give us permission in writing, we may use and disclose your personal and medical information for other purposes. If you give us permission, you have the right to revoke it. This must be in writing too. We cannot take back any uses or disclosures already made with your permission.
You have the following rights regarding the health information that we have about you. Your requests must be made in writing to MMI at the address below.
· Your Right to Inspect and Copy
In most cases, you have the right to look at or get copies of your records. You may be charged a fee for the cost of copying your records.
· Your Right to Amend
You may ask MMI to change your records. If you feel there is a mistake, you have the right to add a statement. You must provide a reason for your request. We can deny your request for certain reasons, but we must give you a written reason for our denial.
· Your Rights to a List of Disclosures
You have the right to ask for a list of disclosures made about you after April 14, 2003. This list will not include the times that information was disclosed for treatment, payment, or health care operations. You may be charged a fee for the cost of copying.
· Your Right to Request Restrictions on Our Use or Disclosure of Information
You have the right to ask for limits on how your information is used or disclosed. We are not required to agree to such request.
·· Your Right to Request Confidential Communications
You have the right to ask that we share information with you in a certain way or in a certain place. For example, you may ask us to send information to your work address instead of your home address. You do not have to explain the basis for your request. We will attempt to honor your request.
MMI can revise this notice at any time in the future. A revised notice will be effective for health information we already have about you as well as any information we may receive in the future. We are required by law to comply with whatever notice is currently in effect. Any changes to our notice will be available at our offices. You may call or stop by to receive a revised one.
HOW TO USE YOUR RIGHTS UNDER THIS NOTICE
· If you believe that your privacy rights have been violated, you have the right to file a complaint with the federal government. You may write to the Secretary of the Department of Health and Human Services. You will find a listing for this department in local telephone directories. You will not be penalized for filing a complaint with the federal government.
· If you want to exercise your rights under this notice or if you wish to communicate with us about privacy issues or if you wish to file a complaint, you may write to:
Privacy Officer
Mid-Michigan Industries, Inc.
2426 Parkway Drive
Mt. Pleasant, MI 48858
Phone: 989-773-6918
Michigan Relay Center: 800-649-3777 (Voice and TDD)
Your request to MMI must be in writing, but we will help you prepare your written request, if you wish. You will not be penalized for filing a complaint.
You have the right to receive an additional copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. Please call or write to MMI to request a copy. This notice will be made available upon request in other languages and alternate formats that meet the guidelines for the Americans with Disabilities Act (ADA).
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Are there any felony charges pending against you? _____ Yes _____ No If yes, please describe:
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Are you legally eligible for employment in the United States? _____ Yes _____ No
(Proof of citizenship or immigration status will be required before obtaining employment.)
Do you have transportation available to attend work or training? _____ Yes _____ No
If yes, please designate: _____ private vehicle _____ public transportation _____ need aide ___________________ other
Guardianship Status:
Own Guardian: _____ Yes (go to next section) _____ No (please complete information below)
Guardian: __________________________________________________________________________________________
Address: _________________________________________ City: ____________________ State: ______ Zip: _________
Phone: _(_________)____________________________ Email: _______________________________________________
Scope of Guardianship: _______________________________________________________________________________
Medical Information:
- If yes, a physician’s order is required and a supply of medication should be submitted.
- If yes, frequency: _____________________________________________________________________
- Action to be taken: ____________________________________________________________________
- If yes, please attach copy of protocols.
Other Considerations: (Information MMI staff needs to know to provide a safe environment.)
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Do you (applicant) have a Behavior Program? _____ Yes _____ No If yes, please attach.
All application information I have provided is true to my knowledge. I authorize MMI to investigate all statements contained in this application to determine my eligibility for participation.
Signature: ____________________________________________________________________ Date: _____/_____/_____
(If not completed by participant, the individual completing application must sign and indicate relationship to participant.)
Referring Agency: ____________________________________________________ Date of Referral: _____/_____/_____
Agency Representative (signature required): ______________________________________________________________