FORMS FOR THE ST. JOSEPH MERCY PARTIAL HOSPITALIZATION PROGRAM
In this packet, you fill find an Activity Therapy Questionnaire, a Medication List, a
Patient Contact Sheet, a Behavioral Admission Form, and various consents. Please
complete these and they will be reviewed with a nurse.
Please use the instructions below when completing the consents. You do not need to
have these papers witnessed. A staff will do that when you arrive. If you have questions
and/or do not agree with the consents, please do not sign the different forms.
Consent for Psychiatric Service
Print your name at top. If you agree, sign and date the consent.
Acknowledgement of Notice of Privacy Practices
Please read this notice prior to completing the consent. If this applies, print your name,
enter your date of birth, sign and date.
Opportunity to Agree or Object
Print your name, enter your date of birth. If you agree, sign and date the consent.
Partial Hospitalization Services Program Expectations
Please read the Program Expectations. If you agree, sign and date the consent.
Outpatient Consent and Authorization
Print your name at top. If you agree with I, II, and III, sign and date the consent. If your
spouse agrees to IV, have him/her write his/her name in space provided and have him/her
sign the form.
General Authorization for Use or Disclosure of Health Information
There are a total of eight papers to review/sign, two for each of the following:
psychiatrist, family members, primary therapist, and family physician. One consent is for
this program to talk and/or release information to a designated person (psychiatrist,
family members, etc.). The second form is for those designated people to be able to talk
to program staff. If you agree with this communication, date and write your name at the
top, write the name(s) of your psychiatrist, etc, and sign the consents at the bottom.
Patient Contact Sheet
Patient Name ____________________________________________________________
Patient Home Phone_______________________________________________________
Patient Cell Phone ________________________________________________________
Patient Emergency Contact:
Name ____________________________________________________________
Phone (h) _____________________________(c) _________________________
Psychiatrist:
Name ____________________________________________________________
Phone ____________________________________________________________
Therapist:
Name ____________________________________________________________
Phone ____________________________________________________________
Patient Registration Form
Behavioral Services
Partial Hospital Adult/Adolescent
Demographics
Today’s Date:___________________________
Patients Last Name:__________________________ Patients First Name:_____________________________ MI _____
Date of Birth:____________________________
Male
Gender:
Female
Address:_________________________________________ City:____________________________________________
State:___________ Zip:___________ County:__________________________ Home Phone:______________________
Social Security #:_________________________
Is Patient Employed?
Yes
No
Employer Name/Address:___________________________________________________________________________
Primary Care Physician:_____________________________________________________________________________
Emergency Contact Information
Emergency Contact:_____________________________________________ Relationship:________________________
Home Phone Number:____________________________ Alternate Phone Number:______________________________
Insurance Information
Name of Insurance:_______________________________ Policy Holder Name:_________________________________
Social Security Number:___________________________ Contract Number:____________________________________
Policy Holder is:
Male
Female
Policy Holder is:
Full Time
Date of Birth:_____________________
Part Time
Retired
Not Employed
Employer Name:_________________________________ Employer Address:__________________________________
FOR STAFF USE ONLY
Please attach a copy of both sides of insurance card(s) and fax to Admitting at 712-3755
Register for:
Diagnostic Eval/Location HOEV
Recur 6A/Location HOPD
Recur 6A/Location HOPA
Attending Physician:_____________________ First Day of Attendance:________________ FIN/CPI#:_________________
NPP Given and Signed
Yes
No
Diagnosis:_________________________________________________
Please make this patient a no information patient.
Behavioral Admission Information Form
Name_____________________________________________________ Date___________________________
Describe the events leading up to your participation in the Huron Oaks program.________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Please describe how you are feeling and the difficulties you are having.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Are there any specific stressors, life changes, or losses in your life right now? (relationship, financial, legal, etc)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
What Symptoms are you experiencing?
□ Confusion
□ Depressed Mood
□ Excessive Fear
□ Anxiety
□ Hallucinations
□ Grief
□ Mood Swings
□ Hopelessness
□ Manic Symptoms
□ Suicidal thoughts
□ Impulsive behavior
□ Worthlessness
□ Sensitivity increased
□ Guilt
□ Anger
□ Loss of energy
□ Agitation
□ Difficulty Concentrating
Have you ever wished you could go to sleep and
not wake up?
□ Unusual thoughts/ideas
□ Sleep Disturbance (decrease)
□ Sleep Disturbance (increase)
□ Weight gain
□ Weight loss
□ Substance withdrawal
□ Symptoms associated with an
eating disorder
□ Psychological Trauma
□ Yes
□ No
□ Yes
□ No
Have you been thinking about how you might do
this?
□ Yes
□ No
Are you intending to act on these thoughts?
□ Yes
□ No
Have you started working out details on how to kill
yourself?
□ Yes
□ No
Have you had thoughts of killing yourself?
Have you ever done anything, started to do anything, or prepared to do anything to end your life?
□ Yes
How long ago did you do any of these?
□ Within the last three months
□ Between three months and a year ago
□ Over one year ago
Do you have access to guns/weapons?
□ Yes
Do you currently engage in self-harm behavior?
□ No
□ Cutting
□ Hair Pulling
□ Burning
□ Head banging
□ Other:____________________________
Have you in the past?
□ No
□ Yes
Type of self-harm______________________
Have you ever threatened to harm or
physically harmed someone?
□ Yes
How many times has this occurred?
□ N/A
How old were you the first time it occurred?
□ 40 or older
Are you having thoughts to harm or kill others
now?
□ Yes
□ No
□ No
□ No
□ 1-2
□ 3-4
□ 20-39
□ 5 or more
□ under 20
□ No
If yes, please explain _________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Please rate the following mood/thoughts on a 0-10 scale 10 = the highest level
Depression _______ Anxiety _______ Suicide _______ Self-harm ________ Harm to Others_______
Allergies
Drug
____________________
____________________
____________________
____________________
Food
____________________
____________________
____________________
____________________
Environment
____________________
____________________
____________________
____________________
Medical History
Diabetes:
□ Type I
□ Type II
□ Hypertension
□ High Cholesterol
□ Hyperlipidemia
□ Heart Attack
□ Heart Failure
□ Atrial Fibrillation
□ Stroke/TIA
□ Head Injury
□ Seizures
□ Hearing Problems
□ Vision Problems
□ Anemia
□ HIV
□ Infection
□ COPD/Respiratory
□ Asthma
□ Sexually transmitted disease
□ Bowel Disease
□ Wound/Cut
□ Cancer
□ Learning Disability
□ Chronic Pain
Other Medical History________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Surgical History
______________________________________________________________ Date _____________________
______________________________________________________________ Date _____________________
______________________________________________________________ Date _____________________
Do you have a history of substance abuse? If yes, please describe.
__________________________________________________________________________________________
_________________________________________________________________________________________
Have you sought treatment? If yes, what type/program?
__________________________________________________________________________________________
How often did you have a drink containing alcohol
in the past year?
In the past year, how many drinks did you typically
have when you drank?
□ never
□ less than monthly
□ 2 to 4 times per month
□ 2-3 times per week
□ 4 or more times per week
□ 1 or 2
□ 3 or 4
□ 5 or 6
□ 7 or 8
□ 10 or more
How often did you have 6 or more drinks on one
occasion in the past year?
□ never
□ less than monthly
□ monthly
□ weekly
□ daily
Have you ever been treated for an alcohol problem
or attended AA?
□ Yes
□ No
Who do you currently reside with?
□ Alone
□ Children
□ Father
□ Mother
What is your employment status?
□ Employed □ Retired □ Unemployed
□ Part-time □ Student □ Other _______________
Highest Education:
□ None
□ High School □ Some College
□ University Degree(s)_________________________
□ Post Graduate Degree(s)______________________
How much do you exercise?
□ Not currently exercising
□ ______ minutes per day ______ times per week
□ Type: ____________________________________
□ Siblings
□ Significant Other
□ Spouse
□ Other:____________________
Are you sexually active? □ Yes □ No Describe your sexual orientation ______________________________
Do you use contraception? □ No □ Yes, type____________________________________________________
Pregnancy Status □ Yes, estimated date of delivery_____________ □ No □ Unknown □ Not Applicable
Date of last menstrual period ________________
What helps you relax or cope?
__________________________________________________________________________________________
Is there someone supportive to you other than your emergency contact that you would like to include in your
contact information?
Name_____________________________ Contact information _______________________________________
Mental Health Treatment History
Illness Description
Illness Date
Hospital or Outpatient Program
Physician/Therapist
Who do you spend time with? _________________________________________________________________
Has there been a change in your social interaction?
□ Yes
□ No
Do you have specific ethnic, cultural, spiritual practices that would affect care?
__________________________________________________________________________________________
Eating Patterns
Type of Diet:
□ Regular diet
□ Gluten free
□ Diabetic
□ Lactose Free
□ Vegetarian
□ Low Cholesterol
□ Low Fat
□ Other _____________________
□ normal eating behaviors
□ binge eating
□ vomit after eating
□ over eating
□ under eating
□ irregular meal times
□ laxative use
□ weight gain
□ weight loss
Usual Weight__________
Current weight ___________
Height_____________
Have you lost weight without trying?
□ Yes
□ No
Have you been eating poorly because of a decreased appetite?
□ Yes
□ No
Have you recently been on tube feedings?
□ Yes
□ No
Do you have any large open wounds or wounds that are not healing?
□ Yes
□ No
Sleeping Patterns
□ normal sleep pattern
□ difficulty awakening
□ difficulty falling asleep
□ early morning awakening
□ frequent urination at night
□ oversleeping
□ middle of night awakening
□ night terrors
□ nightmares
□ restless sleeper
□ sleep walking
□ Current hours sleep per night _______________
Abuse History
Have you ever been sexually, emotionally or physically abused by your partner, caregiver, or someone
important to you?
□ Yes
□ No
Within the past year, have you been hit, kicked or otherwise physically hurt by someone?
□ Yes
□ No
Within the last year, has anyone forced you to have sexual activity?
□ Yes
□ No
Are you afraid of your partner, caregiver, or anyone else?
□ Yes
□ No
If you answered yes to any of the above questions, please explain further.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Tobacco Use
□ never smoker
□ former smoker, quit within the past year
□ former smoker, quit more than a year ago
□ current everyday smoker
□ current some day smoker
Type of Tobacco
□ Cigar
□ Cigarettes
□ Pipe
□ Chewing tobacco
Do you have a history of falling?
□ No
□ Yes
Do you use a walking aid?
□ No
□ Yes
Do you have problems with balance?
□ No
□ Yes
Age started to use__________
Amount of tobacco per day:
_________________________
Immunizations
Have you had a Pneumonia Shot in the past 5 years?
□ No
□ Yes, date_________________
Have you had a Flu Shot this season?
□ No
□ Yes, date_________________
Do you have an Advance Directive or Living Will?
□ No
□ Yes
Do you have a Durable Power of Attorney for Health Care?
□ No
□ Yes
Name of DPOA____________________________
□ I would like information
Name:___________________ Date:___________
Please list drug allergies:_____________________________________
Name of Medication
Dosage
Frequency
Length of time
you've taken this
medication
I have reviewed the Current Medications and have considered then when prescribing new medication
Physician Signature
Date
Activity Therapy Questionnaire
During your admission in the Partial Hospital Program you will be encouraged to participate
in a variety of therapeutic activities called Activity Therapy. The following questions will
help to provide important information in planning activities to best meet your therapeutic
needs.
Which of the following group settings do you feel most comfortable in participating in?
__ Adapted Exercise
__ Educational Presentations
__ Music Therapy
__ Recreational Activities (Games etc.)
__ Spiritual Discussion Group
__ Creative Expression
__ Hands-on Artistic Activities
__ Off Unit Walks
__ Relaxation Techniques Group
__ Treatment Processing Group
Do you have specific physical, emotional or cognitive concerns that may restrict your ability
to participate in an Activity Therapy Group? ___ Yes ___ No
If yes please describe: ___________________________________________________________________
What is the highest level of education you have completed? ___________________
How would you assess your ability to read and write?
___ No Difficulty ___ Some Difficulty ___ Significant Difficulty
Are you experiencing problems in any of the following areas?
__ Depression
__ Racing Thoughts
__ Anxiety
__ Memory/Concentration
__ Coping with Stress
__ Recognizing Harmful Situations
__ Thoughts of Hurting Yourself of Others __ Auditory Hallucinations (Hearing Things)
__ Anger Management
__ Visual Hallucinations (Seeing Things)
__ Fatigue/Sleep Difficulties
__ Taking Prescribed Medications
__ Appetite
__ Alcohol and/or Street Drugs
__ Self-Care/Grooming
__ Utilizing Community Support Services
__ Communicating Needs to Others
__ Starting and Completing a Task
__ Functioning at Home, Work, or School
__ Participating in Leisure Activities
Other: __________________________________________________________________________
Are you currently employed: __ Yes __ No If unemployed, how long? ______________
On average, how many hours per week do you spend at your job? ____________________
What is your main source of transportation?
__ Driving myself __ Transported by friends/family __Bus __Walking Other: _________________
The following categories represent different ways in which you might spend your
leisure or free time. What activities do you enjoy that involve:
Being a Spectator _______________________________________________________________
Creativity/Self Expression _______________________________________________________
Family _________________________________________________________________________
Home Improvement _____________________________________________________________
Intellectual Skills _______________________________________________________________
Physical Activities ______________________________________________________________
Relaxation ______________________________________________________________________
Social Interaction _______________________________________________________________
Spirituality/Support Groups/ Community _________________________________________
________________________________________________________________________________
Travel/Adventure ______________________________________________________________
________________________________________________________________________________
Please list any other activities, which you enjoy that do not fall into these
categories:
_________________________________________________________________________________
_________________________________________________________________________________
What areas would you like to:
Become more involved in? _______________________________________________________
Find our more information about? ________________________________________________
Increase your skill level in? _____________________________________________________
What specific obstacles are you currently experiencing which limit your ability to
participate in a healthy leisure lifestyle? ________________________________________
________________________________________________________________________________
________________________________________________________________________________
Huron Oaks Adult Partial Hospitalization Program
Program Expectations
In order to obtain maximum benefit from the Partial Hospital Program and to protect the
rights and safety of all participating members, the following set of expectations has been
developed. All patients participating in the program are expected to contract with the
program to follow these guidelines.
1. You are expected to be an active participant in your treatment. The program is
short stay and is aimed at the resolution of acute problems. You agree to:
o Work on setting and achieving realistic and positive goals.
o Be on time and attend all groups and activities for which you are
scheduled. The program’s focus is on a group format.
o If you take medications during the day, bring only the dose that you need
for that day. Do not bring full medication bottles to the program unless
requested by your doctor.
o Attend the full program between the hours of 9 a.m. and 3 p.m., unless
your doctor arranges otherwise.
o Notify the program if you are unable to attend for any reason. Three or
more unexcused absences will result in a team conference. At that time,
continuing in the program and possible referral to another program will be
discussed.
o If on any day you are unable to arrive before 10:30 a.m., we will ask you
to take the day off from the program.
o You must stay on program grounds during the program day.
2. No violence will be tolerated. This includes physical and verbal violence against
other persons and destruction of property. You may be billed for
replacement/repair costs.
3. No drinking or use of un-prescribed medications or drugs will be tolerated at any
time (while in the program or at home). This also applies to attending the program
activities under the influence of drugs or alcohol. No alcohol or unprescribed
medications are allowed on the hospital grounds.
4. A smoke free environment is maintained throughout the St. Joseph Mercy
Hospital campus. You may not leave campus to smoke during the program. You
may not enter your car to smoke during the program.
5. The Partial Hospitalization Program is a safe environment to ensure that patients
have the opportunity to make full use of the treatment offered. You are expected
to respect the rights of others in the program. All information about other patients
is strictly confidential and show not be shared with anyone outside the program.
The program strongly discourages patients from forming personal relationships
that extend beyond the scope of the treatment service, due to the intense
vulnerability that can sometimes develop in this setting. If such relationships do
develop, patients are encouraged to discuss the situation with their attending
psychiatrist and with the Adult Partial Hospital staff. Depending on the situation,
dismissal from the program may be required to maintain patient boundaries.
6. Behavior that is disruptive, abusive, or in other ways prevents others from
participating in the program will not be tolerated. This includes:
o Arriving late to the program, late to groups, or leaving early.
o Ridiculing others because of their problems or differences.
o Criticizing others.
o Undermining others’ treatment programs.
7. You are asked not to be in the parking lot, in your car, unless you are arriving to
or departing from the program. You may not leave the program in your car during
breaks, as we are liable for your safety during program hours.
8. Cell phones should be turned off or turned to vibrate during groups. The front
desk phone number may be used for emergency contact.
9. The Partial Hospital Program is not responsible for personal property lost or
stolen while you are a participant in the program. Lock valuables in your car or
keep with you during the day.
10. Patients are expected to consider their participation in the program as similar to a
job, in which active engagement is necessary, as opposed to a facility in which
treatment is passively received. An active approach is encouraged.
11. A patient’s attending psychiatrist is her/his primary therapist in the program. In
addition, each patient is assigned a case manager from the Adult Partial Program
staff, whose function is to help arrange and coordinate services.
Behaviors that are disruptive to others, dangerous to you, and/or dangerous to others will
result in corrective action and/or discharge from the program and referral to an
appropriate level of care. These behaviors are:
o
o
o
o
Psychiatric symptoms disruptive to the group
Threats of suicide
Repeated failure to attend scheduled groups
Possession of contraband including unauthorized medication, alcohol, and
weapons.
o
o
o
o
o
Substance abuse while enrolled in the program but offsite
Sexual advances towards other patients, staff, or visitors
Engaging in personal relationship with other patients
Trading or selling items to other patients
Repeated violation of group rules (i.e. leaving the room repeatedly, interrupting
others, disrespecting other group members, side conversations, other distracting or
disrespectful behavior).
Behaviors that will result in automatic immediate discharge from the program or transfer
to an appropriate level of care are:
o Suicide attempts or threats judged to be active/planned, with intent
o Aggression towards staff, patients, or visitors, including verbal threats,
intimidation, and any touching or attempts to touch in an aggressive manner
o Serious self mutilation that results in an ER visit
o Substance use on site
o Unwanted sexual contact with another patient, even when consensual
o Destruction of property with intent to destroy property, including small things
such as a plant or a plate
o Possession of a lethal weapon such as a gun, knife, taser gun
o Possession of illicit drugs
Saint Joseph Mercy Health System
Opportunity to Agree or Object
Behavioral Health Services
Federal Privacy Laws allow you the opportunity to object to certain uses of your Protected Health
Information (PHI). Additional protections are in place for individuals seeking behavioral health services.
Because of these protections, two of the three objections will be automatically in place when you seek
behavioral health services at Saint Joseph Mercy Health System..
Facility Directory
This objection relates to being included in our facility directory. The directory is a list of patients
currently in our hospitals. If you are admitted to our inpatient behavioral health unit, this objection will
automatically be in place. This means that callers or visitors would be told “I’m sorry, we have no
information on a person by that name”.
If you are admitted to the hospital for other reasons, you may choose to be in the directory or exclude
yourself from the directory. If you choose to be in the directory, our employees would be able to provide
visitors or callers who ask for you by name with your room number and a general description of your
condition (using words like “good”, “serious” or “critical”). If a clergy came in and asked for you by
name or by religion, our staff would also share your location, condition, and religion with the clergy. If
you decide not to be in the facility directory, callers or visitors would be told “I’m sorry, we have no
information on a person by that name”. You can make arrangements with your caregiver so that a family
spokesperson can call directly for information.
I object to being included in the facility directory for non-behavioral health services
Family Members or Friends Involved in Your Care or Helping to Pay for Your Care
This objection relates to sharing information with family or friends that will help to take care of you or
help to pay for your care. If you are here for behavioral health services, we will not share information
with family members or friends involved in your care or helping to pay for your care without your
authorization.
If you are accessing services for other reasons, such as coming in for pneumonia or seeing your primary
care doctor for medical reasons, we will share limited information with people who are a part of your
care so that they can assist you in your recovery. For example, we may discuss information with your
spouse regarding which medications you should take and when. We would only share this kind of
information with family and friends who are part of your care, not with people who are just coming to
visit or calling to check on your general condition. If you decide to choose this objection, you will need
to identify the people we cannot share information with.
I object to sharing information with the following family or friends for non-behavioral health
services (please include name and relationship):
__________________________________________________________________________________
03/03
Pg. 1
Disaster Relief
This objection relates to sharing information as part of disaster relief. Should you be involved in a
disaster, we would share limited information with an agency like the Red Cross so that they could notify
your family of your location or condition. If you select this objection, we may still share information
only if it is necessary for us to respond appropriately to the disaster.
I object to being included in the facility directory for behavioral health and non-behavioral health
services
_________________________________________
Individual’s Name (Please Print)
_________________________________________
Signature of Individual or Personal Representative
_________________________________________
Signature of Workforce Member
03/03
____________
_________________
Date of Birth
Medical Record Number
________________________
Date
_________________________
Date
Pg. 2
Effective Date: April 14, 2003
Saint Joseph Mercy Health System
06132012.6
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Saint Joseph Mercy Health
System (referred to as SJMHS
throughout the rest of this
document) understands that
your health information is
highly personal, and we are
committed to safeguarding
your privacy. SJMHS is
required by law to maintain
the privacy of individually
identifiable patient health
information (this information
is “protected health
information” and is referred to
as “PHI” throughout the rest
of this document). PHI
includes identifiable
information about your
health care and payment for
that health care. We are also
required to provide patients
with a Notice of Privacy
Practices regarding PHI.
We are required to post this
Notice in a prominent place
within our facility. We will
only use or disclose your PHI
as permitted or required by
applicable state law. This
Notice applies to your PHI
in our possession including
the medical records generated
by us.
This Notice applies to the
delivery of health care by
SJMHS and its medical staff
in our hospitals, outpatient
departments, clinics, home
care and hospice programs,
system-owned physician
practices, and pharmacies.
This Notice also applies to the
utilization review and quality
assessment activities of Trinity
Health and SJMHS as a
member of Trinity Health.
I. Permitted Use or Disclosure
A.Treatment: SJMHS will use and disclose your
PHI in the provision and coordination of health
care to carry out treatment functions.
■
■
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■
■
■
■
■
sharing the necessary information to obtain
pre-approval for payment for treatment from
your health plan.
■
■
SJMHS is a Catholic sponsored health care
provider. Spiritual care providers, or chaplains,
are members of our care staff and will be a part
of SJMHS’s team of care providers who use your
medical information to provide health care services
to you when you are in SJMHS’s facilities.
C. Health Care Operations: SJMHS will use
and disclose your PHI during routine health
care operations including quality assurance,
utilization review, medical review, internal
auditing, accreditation, certification, licensing
or credentialing activities of SJMHS, and for
educational purposes.
Different departments or areas of SJMHS will
share medical information about you in order to
coordinate specific services, such as lab work,
x-rays and prescriptions.
■
SJMHS will disclose your medical information
to people or entities outside SJMHS who will
be involved in your medical care after you
leave SJMHS, such as family members, friends,
community clergy and others who will provide
services that are part of your care.
SJMHS will share certain information such as
your name, address, employment, insurance
carrier, emergency contact information and
appointment scheduling information in an effort
to coordinate your treatment with us and with
other health care providers.
SJMHS will use and disclose your PHI to inform
you of, or recommend possible treatment
options or alternatives that will be of interest to
you.
SJMHS will use and disclose PHI to contact you
as a reminder that you have an appointment for
treatment or medical care at SJMHS.
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If you are an inmate of a correctional institution or
under the custody of a law enforcement officer,
SJMHS will disclose your PHI to the correctional
institution or law enforcement official.
The medical information will be disclosed
to an insurance company, third party payer,
third party administrator, health plan or other
health care provider (or their duly authorized
representatives) involved in the payment of your
medical bill and will include copies or excerpts
of your medical records which are necessary
for payment of your account. It will also include
SJMHS will disclose PHI to other health
care providers who are engaged in obtaining
payment for care.
For instance, SJMHS will need to share
your demographic information, diagnosis,
treatment plan and health status for population
based activities relating to improving health or
reducing health care costs, protocol development,
case management and care coordination, and
contacting health care providers and patients
with information about treatment alternatives,
in order for us to operate our business in
an efficient, safe and legal manner. SJMHS
will need to share your PHI for customer
service activities. SJMHS also contributes to
databases compiled for benchmarking and
quality improvement.
D.Other Uses and Disclosures: As part
of treatment, payment and health care
operations, we may also use your PHI for the
following purposes:
B.Payment: SJMHS will disclose PHI about
you for the purposes of determining coverage,
eligibility, funding, billing, claims management,
medical data processing, stop loss / reinsurance
and reimbursement.
SJMHS will disclose PHI to collection
agencies and other subcontractors engaged
in obtaining payment for care.
SJMHS will disclose all or any portion of your
patient medical record information to your
attending physician, consulting physician(s),
nurses, technicians, medical students and other
health care providers who have a legitimate need
for such information in your care and continued
treatment.
Fundraising Activities: SJMHS maintains a
database of information to contact individuals
for fund-raising initiatives designed to expand
and improve the services and programs we
provide to the community. The information
we use includes name, address, telephone
number, age, gender and dates of service.
SJMHS may disclose limited PHI from
this database to a company contracted
to conduct fundraising for SJMHS. This
company will use your PHI only for the
purposes of fundraising for SJMHS. You may
be included in this database. If you do not
wish to be contacted for fund-raising efforts,
please notify us in writing at Development
Department, P.O. Box 995, Ann Arbor, MI
48106-0995.
Health Care Research: SJMHS may disclose
your PHI without your Authorization to health
care researchers who request it for certain
types of health care research projects (typical
– Continued on next page
projects involve mailing surveys or collecting
data from medical records); however, with
very limited exceptions such disclosures
must be cleared through a special approval
process before any PHI is disclosed to the
researchers. Researchers will be required to
safeguard the PHI they receive.
■
Information and Health Promotion
Activities: SJMHS will use and disclose
some of your PHI for certain health promotion
activities. For example, your name and
address will be used to send you newsletters
or general communications. SJMHS will also
send you information based on your own
health concerns. SJMHS may send you
this information if it has determined that
a product or service may help you. The
communication will explain how the product
or service relates to your well being and can
improve your health.
More Stringent State and Federal Laws:
The information in this notice complies with
the requirements of the Health Insurance
Portability and Accountability Act (HIPAA)
regulations. In some cases, other State
or Federal Laws may be more stringent
than the HIPAA regulations. SJMHS will
continue to abide by these more stringent
state and federal laws. State law is more
stringent when the individual is entitled to
greater access to records than under HIPAA
and when under state law the records are
more protected from disclosure than under
HIPAA. Examples of state laws include: In
Michigan patients have more rights of access
to behavioral health information under
Michigan law than under HIPAA and the state
law defines a minimum necessary standard
for release of mental health information.
Disclosure is permitted with consent and
for treatment without consent but only in
an emergency. Minors in Michigan have
more rights to confidentiality and protection
of certain information (reproductive health,
behavioral health and substance abuse) than
under HIPAA. State law requires facilities
to adopt policies regarding release of
information outside the facility. If the facility
policy requires consent for release, then
consent will be required. State law genetic
and HIV testing and disclosure consents
remain in place. Federal laws that are more
stringent include applicable internet privacy
laws, such as the Children’s Online Privacy
Protection Act and the federal laws and
regulations governing the confidentiality
of health information regarding substance
abuse treatment.
II. Permitted Use or Disclosure with an Opportunity for You
to Agree or Object
A. Family/Friends: SJMHS will disclose PHI about you to a friend or family member
who is involved in your medical care. SJMHS will also give information to family
members, friends or others who help you pay for your care. In addition, SJMHS will
disclose PHI about you to an agency assisting in a disaster relief effort so that your
family can be notified about your condition, status and location. You have a right
to request that your PHI not be shared with some or all of your family or friends.
B. Facility Directory: SJMHS will include certain limited information about you in the
Facility Directory. The Facility Directory is a list of people who are currently patients
in the hospital. This information will include your name, location in SJMHS, your
general condition (“good,” “fair,” “serious,” or “critical”) and your religious and/or
congregational affiliation. This is so your family, friends, or clergy can visit you in
the hospital and know how you are doing. The directory information, except for
your religious and/or congregational affiliation, will be disclosed to people who
ask for you by name. The directory information including your religious and/or
congregational affiliation will be given to a community clergy member, such as a
pastor, priest, rabbi, or imam, who asks for you by name, by religious affiliation or
by congregational affiliation. If you request us to do so, we will inform your clergy
directly of your location in SJMHS. You have the right to request that your name
not be included in the Facility Directory. If you request to opt out of the Facility
Directory, we cannot inform visitors or callers of your presence, location, or general
condition. Visitors or callers will be told that we have no information on a person
by that name.
C.Promotional Communications: SJMHS does not share or sell your PHI to
companies that market health care products or services directly to consumers for
use by those companies to contact you, such as drug companies. SJMHS does
maintain a database of individuals for promotional communications. This database
includes individuals to whom SJMHS may have sent health improvement or health
promotion materials and news about SJMHS. SJMHS sends information to the
individuals in this database about the programs and services of SJMHS. You may
be included in this database. If you do not wish to be contacted for promotional
communications, please notify us in writing at Marketing Department, P.O. Box 995,
Ann Arbor, MI 48106-0995.
D. Media Condition Reports: SJMHS may release information for an update to the
media if the media requests information about you using your full name and after we
have given you an opportunity to agree or object. The following information may then
be disclosed: your condition described in general terms that do not communicate
specific medical information, such as “good,” “fair,” “serious,” or “critical.”
III. Use or Disclosure Requiring Your Authorization
A.Marketing: SJMHS is permitted to use your PHI for the purpose of sending you
information about SJMHS’s products or services. However, we must obtain your
authorization to use your PHI if SJMHS is receiving payment in exchange for the
marketing communication. SJMHS does not provide your PHI to any other person
or company for marketing of their products or services.
B.Research: For many types of research, SJMHS will be required to obtain your
authorization before allowing the researchers to use or disclose your PHI. A special
approval process is required for these types of research projects before your PHI
is shared.
C.Other Uses: Any uses or disclosures that are not for treatment, payment or
operations and that are not permitted or required for public policy purposes or by
law will be made only with your written authorization. Written authorizations will let
you know why we are using your PHI. You have the right to revoke an authorization
at any time.
D. General Authorization for Use or Disclosure of Health Information forms are
available by contacting the Health Information Management Department at the
hospital associated with your care (734-712-3526 for SJMHS Ann Arbor, Saline
and Livingston; 734-655-2416 for St. Mary Mercy Hospital; 734-475-3982 for
Chelsea Community Hospital); or by printing the form from the hospital’s web site
at http://www.sjmercyhealth.org.
IV. Use or Disclosure Permitted by Public Policy or Law without
your Authorization
V. Your Health Information Rights
A.Law Enforcement Purposes: SJMHS
will disclose your PHI for law enforcement
purposes as required by law, such as
responding to a court order or subpoena,
identifying a criminal suspect or a missing
person, or providing information about a
crime victim or criminal conduct.
A.Right to Inspect and Copy: You have the right to access your PHI and to inspect
and copy your PHI as long as we maintain it except for: psychotherapy notes,
information that will be used in a civil, criminal or administrative action or proceeding,
and where prohibited or protected by law. You also have the right to request your
PHI in electronic format if the service where you received your care is using an
electronic health record. SJMHS will deny your request for access to your PHI
without giving you an opportunity to review that decision if:
SJMHS must maintain all records concerning your hospitalization and treatment by
SJMHS. You have the following rights concerning your PHI:
about you when required by federal, state or
local law to make reports or other disclosures.
SJMHS also will make disclosures for judicial
and administrative proceedings such as
lawsuits or other disputes in response to a
court order or subpoena. SJMHS will disclose
your medical information to government
agencies concerning victims of abuse, neglect
or domestic violence. SJMHS will report drug
diversion and information related to fraudulent
prescription activity to law enforcement and
regulatory agencies. Specialized government
functions will warrant the use and disclosure
of PHI. These government functions will
include military and veteran’s activities,
national security and intelligence activities,
and protective services for the President and
others. SJMHS will make certain disclosures
that are required in order to comply with
workers’ compensation or similar programs.
C.Coroners, Medical Examiners, Funeral
Directors: SJMHS will disclose your PHI to
a coroner or medical examiner. For example,
this will be necessary to identify a deceased
person or to determine a cause of death.
SJMHS will also disclose your medical
information to funeral directors as necessary
to carry out their duties.
D.Organ Procurement: SJMHS will disclose
PHI to an organ procurement organization
or entity for organ, eye or tissue donation
purposes.
E.Health or Safety: SJMHS will use and
disclose PHI to avert a serious threat
to health and safety of a person or the
public. SJMHS will use and disclose PHI to
Public Health Agencies for immunizations,
communicable diseases, etc. SJMHS will
use and disclose PHI for activities related to
the quality, safety or effectiveness of FDAregulated products or activities, including
collecting and reporting adverse events,
tracking and facilitating product recalls,
etc. and post marketing surveillance. Any
patient receiving a medical device subject
to FDA tracking requirements may refuse to
disclose, or refuse permission to disclose,
their name, address, telephone number and
social security number, or other identifying
information for the purpose of tracking.
You don’t have the right to inspect the information; or it is otherwise prohibited or
protected by law;
■
■
■
■
■
■
You must make your requests to access and copy your PHI in writing to SJMHS. Request
to Access Health Information forms are available by contacting the Health Information
B. Required by Law: SJMHS will disclose PHI
You are an inmate at a correctional institution and obtaining a copy of the information
would risk the health, safety, security, custody or rehabilitation of you or other
inmates;
The disclosure of the information would threaten the safety of any officer, employee or
other person at the correctional institution or who is responsible for transporting you;
You are involved in a clinical research project and SJMHS created or obtained the PHI
during that research. Your access to the information will be temporarily suspended
for as long as the research is in progress;
SJMHS obtained the information that you seek access to from someone other than
the health care provider under a promise of confidentiality and your access request
is likely to reveal the source of the information; or
Under other limited circumstances. In these instances, however, SJMHS will allow
the review of its decision by a health care professional that SJMHS has chosen. This
person will not have been involved in the original decision to deny your request.
Management Department or by printing the form from the hospital web site at
http://www.sjmercyhealth.org. SJMHS will respond to your request within 30 days of
its receipt. If SJMHS cannot, SJMHS will notify you in writing to explain the delay and
the date by which we will act on your request. In any event, SJMHS will act on your
request within 60 days of its receipt.
You may be required to pay a reasonable copying fee for your request. You will be
provided with information regarding fees when you make your request.
B. Right to Amend: You have the right to amend your PHI for as long as SJMHS
maintains it. However, SJMHS will deny your request for amendment if:
SJMHS did not create the information;
The information is not part of the designated record set;
■ The information would not be available for your inspection
(due to its condition or nature); or
■ SJMHS has found the information to be accurate and complete.
■
■
If SJMHS denies your request to amend your PHI, SJMHS will notify you in writing with
the reason for the denial. SJMHS will also inform you of your right to submit a written
statement disagreeing with the denial. You may ask that SJMHS include your request
for amendment and the denial any time that SJMHS discloses the information that you
wanted changed. SJMHS may prepare a rebuttal to your statement of disagreement
and will provide you with a copy of that rebuttal.
You must make your request for amendment of your PHI in writing to SJMHS, including
your reason to support the requested amendment. Request to Amend or Correct Health
Information forms are available by contacting the Health Information Management
Department or by printing the form from the hospital web site at http://www.
sjmercyhealth.org. SJMHS will respond to your request within 60 days of its receipt. If SJMHS
cannot, SJMHS will notify you in writing to explain the delay and the date by which SJMHS
will act on your request. In any event, SJMHS will act on your request within 90 days of its
receipt.
C. Right to an Accounting: You have a right to receive an accounting of the disclosures
of your PHI that SJMHS made, except for the following disclosures:
■
■
■
■
■
■
■
To carry out treatment, payment or health care operations;
In response to an authorization signed by you
To you;
To persons involved in your care;
For national security or intelligence purposes;
To correctional institutions or law enforcement officials; or
– Continued on next page
That occurred prior to April 14, 2003.
For each disclosure, you will receive: the date of the disclosure,
the name of the receiving organization and address if known, a
brief description of the PHI disclosed and a brief statement of the
purpose of the disclosure or a copy of the written request for the
information, if there was one.
You must make your request for an accounting of disclosures of
your PHI in writing to SJMHS. Forms are available by contacting the
Health Information Management Department or by printing the
form from the hospital web site at http://www.sjmercyhealth.org.
You must include the time period of the accounting, which may not
be longer than 6 years. SJMHS will respond to your request within
60 days from its receipt. If SJMHS cannot, SJMHS will notify you
in writing to explain the delay and the date by which SJMHS will act
on your request. In any event, SJMHS will act on your request within
90 days of its receipt.
In any given 12-month period, SJMHS will provide you with an accounting
of the disclosures of your PHI at no charge. Any additional requests
for an accounting within that time period will be subject to a reasonable
fee for preparing the accounting. Contact Health Information
Management for information on current fees.
D.Right to Request Restrictions: You have the right to request
restrictions on certain uses and disclosures of your PHI to carry
out treatment, payment or health care operations functions.
SJMHS will consider your request, but is not required to agree
to it. For example, you may ask that your name not be used
in the waiting room or that information about your expected
discharge date not be shared with your family. A request for a
restriction must be made in writing. Request for Restriction on
Uses and Disclosures of Health Information forms are available
by contacting the Health Information Management Department
or by printing the form from the hospital web site at http://www.
sjmercyhealth.org.
You have a right to limit release of PHI to family, friends, or in the
facility directory (see Section II – Opportunity for You to Agree
or Object). You also have the right to request a restriction on
disclosure of your PHI to a health plan (for purpose of payment
or health plan operations) in cases where you’ve paid out of
pocket, in full, for the items received or services rendered.
E.Right to Confidential Communications: You have the right to
receive confidential communications of your PHI by alternative
means or at alternative locations. For example, you may request
that SJMHS only contact you at work or by mail. A request for
a confidential communication must be made in writing. Request for
Confidential Communications forms are available by contacting
the Health Information Management Department or by printing
the form from the hospital web site at http://www.sjmercyhealth.
org.
F. Right to Receive a Copy of this Notice: You have the right to
receive a paper copy of this Notice of Privacy Practices, upon
request. A copy may also be printed from the SJMHS web site
at http://www.sjmercyhealth.org.
VI. Breach of Unsecured PHI
If a breach of unsecured PHI occurs which poses a significant risk
of harm to you, SJMHS will notify you that a breach in the privacy
or security of your PHI has occurred.
VII. Complaints
If you believe your privacy rights have been violated, you may file a
complaint with SJMHS or with the Secretary of the Department of
Health and Human Services. Complaints may be submitted in writing
or by calling the Patient Relations Department at 734-712-2700 or the
Privacy Officer at 734-712-4542. For St. Mary Mercy Hospital related
complaints, contact the Privacy Officer at 734-655-1409. Privacy
Complaint forms for written complaints are available by calling the
above numbers, or by printing the form from the hospital’s web site
at http://www.sjmercyhealth.org. SJMHS will acknowledge receipt
of your complaint, either verbally or in writing, within a reasonable
period of time. SJMHS assures you that there will be no retaliation
for filing a complaint.
VIII. Sharing and joint use of your Health Information
In the course of providing care to you and in furtherance of the SJMHS’s
mission to improve the health of the community, SJMHS will share your
PHI with other organizations as described below who have agreed to
abide by the terms described below:
A. Medical Staff: The medical staff and SJMHS participate together in
an organized health care arrangement to deliver health care to you at
SJMHS. Both SJMHS and its medical staff have agreed to abide by
the terms of this Notice with respect to PHI created or received as
part of delivery of health care services to you in SJMHS. Physicians
and allied health care providers are members of SJMHS’s medical
staff and will have access to and use of your PHI for treatment,
payment and health care operations purposes related to your care
within SJMHS. SJMHS will disclose your PHI to the medical staff
for treatment, payment, and health care operations.
B. Business Associates: SJMHS will use and disclose your PHI to
business associates contracted to perform business functions on its
behalf including Trinity Health, its parent company who performs
certain business functions for SJMHS. Whenever an arrangement
between SJMHS and another company involves the use or disclosure
of your PHI, that business associate will be required to keep your
information confidential.
C. Membership in Trinity Health: SJMHS, a member of Trinity Health,
and Trinity Health participate together in an organized health care
arrangement for utilization review and quality assessment activities.
We have agreed to abide by the terms of this Notice with respect
to PHI created or received as part of utilization review and quality
assessment activities of Trinity Health and its members. Members
of Trinity Health will abide by the terms of their own Notice of Privacy
Practices in using your PHI for treatment, payment or healthcare
operations. SJMHS and other hospitals, nursing homes, and health
care providers in Trinity Health share your PHI for utilization review and
quality assessment activities of Trinity Health, the parent company,
and its members. Members of Trinity Health also use your PHI for your
treatment, payment to SJMHS and/or for the health care operations
permitted by HIPAA with respect to our mutual patients.
D. Affiliations: SJMHS is affiliated with the following health care
organizations in which SJMHS is an owner or co-owner:
St. Joseph Mercy Hospital, St. Joseph Mercy Saline Hospital, St.
Joseph Mercy Livingston Hospital, St. Mary Mercy Hospital, Chelsea
Community Hospital, St. Joseph Mercy Home Care, St. Joseph Mercy
Hospice, St. Joseph Mercy Livingston Home Care, St. Joseph Mercy
Livingston Hospice, St. Joseph Mercy Pharmacy, St. Joseph Mercy
Medical Group Physician Offices, Michigan Heart, St. Joseph Mercy
Woodland Health Center, St. Joseph Mercy Canton Health Center,
St. Joseph Mercy Maple Health Building, St. Joseph Mercy Arbor Health
Center, St. Joseph Mercy Reichert Health Center, Chelsea Community
Hospital Laboratory, ChelseaCare Home Health and Pharmacy, Chelsea
Community Hospital Physician Practices, Warde Medical Laboratory/
Michigan Co-Tenancy Laboratory, Avant Imaging.
SJMHS will share your PHI with these organizations for purposes of your
treatment, payment and health care operations by these organizations.
IX. Additional Information
To obtain further information regarding the issues covered by this Notice
of Privacy Practices:
For Ann Arbor, Chelsea, Livingston and Saline, please contact:
Privacy Officer, 5301 East Huron River Drive, PO Box 995,
Ann Arbor, MI 48106-0995. Telephone: 734-712-4542.
For St. Mary Mercy, please contact:
Privacy Official, 36475 Five Mile Road, Livonia, MI 48154.
Telephone: 734-655-1409.
IX. Changes to this Notice
SJMHS will abide by the terms of the Notice currently in effect. SJMHS
reserves the right to change the terms of its Notice and to make the
new Notice provisions effective for all PHI that it maintains. SJMHS
will provide you with the revised Notice at your first visit following the
revision of the Notice.
292346 R 6/12 (M) (09001)
Saint Joseph Mercy Health System
Acknowledgment of Notice of Privacy Practices
I acknowledge:
A copy of the provider’s Notice of Privacy Practices was made available to me at the place where I
went for health care services. A copy was available for me to keep if I desired.
The Notice of Privacy Practices was posted in a clear and prominent location where I could read it.
If I came in for health care services in an emergency situation, I was able to view the Notice as soon as
reasonably possible after the emergency situation.
I received the Notice of Privacy Practices no later than the first day I received health care services in
person. If I received healthcare services by telephone or electronically, a copy of the notice was
mailed to me or sent to me electronically
__________________________________
_______________
Individual’s Name (Please Print)
Date of Birth
_________________________________________
Signature of Individual or Personal Representative
_________________
Medical Record #
________________________
Date
If you have received this form by mail, please return signed form to:
___________________________________________________________________________________
___________________________________________________________________________________
For Office Use Only:
If an acknowledgment is not obtained, document below provider’s good faith efforts to obtain the
acknowledgment and the reason why the acknowledgment was not obtained:
__________________________________
_______________
Individual’s Name (Please Print)
Date of Birth
_________________
Medical Record #
Date of attempt to obtain Acknowledgment: ___________________________________
Reason Acknowledgment was not obtained:
Individual declined to sign acknowledgment
Individual stated that he/she already received a copy of Notice and Objection Information Sheet
Individual arrived under emergency circumstances.
Individual was not present to sign acknowledgment (services provided via telephone/electronically/through a
3rd party)
Acknowledgement Form, Notice of Privacy Practices and Objection Information Sheet:
Sent with individual’s pharmacy prescription
Mailed within one (1) business day
Provided electronically at time of service, with return receipt requested
Date Return Receipt Received ______________ (if greater than 2 working days from date of
service, assume transmission has failed and mail documents)
Other _____________________________________________________________
___________________________
_________________________
Signature of Workforce Member
Revised 06/04
Date
Pg. 1
Stores # 09019
When Receiving Mental Health Services in Michigan
“Rights is Everybody’s Business”
Michigan Department of Community Health
Office of Recipient Rights
Rick Snyder, Governor
James K. Haveman, Director
SECTION 1: GENERAL INORMATION ABOUT RIGHTS
When you receive mental health services, Michigan's Mental Health Code, as well as other laws,
safeguard your rights. Staff are responsible to protect your rights when they provide services to you.
You are encouraged to ask questions about your treatment and about your rights and to make
suggestions that you feel are in your best interest. If you believe your rights have been violated, you
should inform the Rights Officer/Advisor at the location where you are receiving services.
Notice
Mental Health Code Sections 706, 706a
When you make a request for, or begin to receive, mental health services, you are to be given
information about the rights guaranteed in Chapters 7 and 7A of the Code. This booklet meets that
requirement and provides you a summary of the information and rights contained in those chapters.
A complete copy of Chapters 7 and 7A are available from your service site.
If you receive services from a community mental health services program, you, or your family, should
also be given a pamphlet containing information regarding available resources, advocacy and support
groups, and other relevant information, including how to contact Michigan Protection and Advocacy
Services, Inc.
Competency
Mental Health Code Section 702
Just because you receive mental health treatment or services does not mean that you are incompetent.
You still have the right to have a driver's license, marry and divorce, make a will, buy and sell property,
manage your own affairs and decide most things about your life. You will continue to be treated as
competent unless a court has decided that you are legally incompetent and has appointed a guardian
for you.
A guardian is authorized by a judge to make certain decisions for you. For some people, a guardian
makes major decisions; for others, the guardian decides only those specific things listed in a court order.
If you have a guardian and you think you should be able to make more decisions for yourself, or you
think you don't need a guardian, or that you need a different guardian, then you, or someone on your
behalf, may go to the court and ask (petition) for a change of guardianship.
Consent
Mental Health Code Section 100 a [17]; Administrative Rule 330.7003
You must give INFORMED CONSENT in order to receive treatment or to have confidential information
about you provided to others by the agency from which you are receiving services. In order to be able
to give informed consent you must have:
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KNOWLEDGE
You must be told about the risks, benefits, and available alternatives to a course of treatment or
medication.
UNDERSTANDING
You must be able to reasonably understand the information you are given including the risks,
benefits, available options or alternatives, or other consequences.
Your decision to provide consent must be VOLUNTARY. You should not be forced or pressured into a
decision. Unless you are a minor or have a guardian, the choice you make should be your and yours only.
This consent must either:
 Be in writing and signed by you, your legal representative, or
 Be your verbal agreement which is witnessed and put in writing by someone who is not treating
you at the time.
Dignity and Respect
Mental Health Code Section 704, 711
The law requires all mental health service providers to assure that you are treated with dignity and
respect. Examples of staff not showing respect include calling you names, making fun of you, teasing, or
harassing you.
Your FAMILY MEMBERS also have the right to be treated with dignity and respect. In addition, they must
be given:
An opportunity to provide information about you to your treating professionals.
An opportunity to request, and receive, general education information about the nature of mental
disorders, medications and their side effects. Information about available support services,
advocacy groups, financial assistance, and coping strategies.
Freedom from Abuse and Neglect
Mental Health Code Section 722; Administrative Rule 330.7001, 7035
WHEN RECEIVING MENTAL HEALTH SERVICES YOU HAVE THE RIGHT NOT TO BE PHYSICALLY, SEXUALLY, OR
OTHERWISE ABUSED AND THE RIGHT NOT TO BE NEGLECTED.
ABUSE MAY TAKE MANY FORMS. IF A STAFF PERSON
MAKES ANY PHYSICAL CONTACT WITH YOU FOR SEXUAL PURPOSES, OR IF YOU ARE SEXUALLY HARASSED IT IS ABUSE. IF
STAFF CAUSE YOU TO BE INJURED IN ANY WAY OR USE UNREASONABLE FORCE IN A PHYSICAL MANAGEMENT
SITUATION, OR CAUSE YOU EMOTIONAL HARM, IT MAY BE ABUSE. IF YOUR FUNDS ARE MISUSED, IT IS ABUSE. IF STAFF
ARE VERBALLY ABUSIVE TO YOU, IT IS ABUSE. IF STAFF FAIL TO DO SOMETHING THEY ARE SUPPOSED TO DO WHEN THEY
ARE CARING FOR YOU, OR IF THEY SOMETHING THEY SHOULDN’T DO AND IT RESULTS IN HARM TO YOU OR HAS THE
POTENTIAL TO HARM YOU, THEN THIS MAY BE NEGLECT. IF YOU FEEL YOU HAVE BEEN ABUSED OR
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NEGLECTED, OR SUSPECT ANOTHER RECIPIENT HAS BEEN, YOU SHOULD REPORT IT IMMEDIATELY TO
A STAFF PERSON AND TO YOUR RECIPIENT RIGHTS OFFICER/ADVISOR.
Fingerprints, Photographs, Audiotape, Videotape, and Use of One-Way Glass
Mental Health Code Section 724
You have the right not to be fingerprinted, photographed, recorded on audio or video, or viewed
through a one-way glass unless you or your legal representative agree in writing.


If someone wants to photograph, videotape, or record you for educational, informational, social or
treatment purposes, that person must obtain your permission. If you object, it will not be done.
When they are no longer needed, or upon discharge, any fingerprints, photographs, audiotapes, or
videotapes in your record must either be destroyed or given to you.
While doing an investigation to determine if your rights were violated, the Rights Officer/Advisor may
need to take your picture. This will be kept in your confidential records maintained in the Rights Office.
Confidentiality
Mental Health Code Section 748, 946
You have the right to have information about your mental health treatment kept private. Information
about you and your treatment cannot be given to anyone except as required or allowed by law. Listed
here are examples of when confidential information may be released:






02/2013
If a law or a court order requires your records be released.
If you, or your legal representative, consents.
If needed to get benefits for you or to get reimbursement for cost of treatment.
If it is needed for research or statistical purposes, with certain safeguards regarding
identification.
If you die and your surviving spouse or other close relative needs the information to
apply for and receive benefits.
If you tell your mental health professional that you are going to harm another person,
he/she may have to notify the police and the person who you threaten to harm.
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Access to Your Record
Mental Health Code Section 748
You have the right to see your treatment record. Upon request, you or your legal representative may
read or get a copy of all or part of your record. There may be a charge for the cost of copying.
If you are an adult and the court has not judged you incompetent (appointed a guardian for you),
information entered in your record after March 28, 1996 may not be withheld from you under any
circumstances.
If you are denied access to your record, you, or someone on your behalf, may appeal the decision.
Contact your rights officer/advisor for information about the appeal process.
If you (or your legal representative) believe(s) your record contains incorrect information, you or they
may place a statement in your record which corrects that information. You may not remove what is
already in the record.
Environmental Rights
Mental Health Code Section 708
You have the right to treatment in a place which is clean and safe
If you are receiving services from a residential program, the place where you live must have good
lighting, enough heat, fresh air, hot and cold water, a bathroom with privacy, personal storage space. It
should also be free from unpleasant smells.
Civil Rights
Mental Health Code Section 740; Administrative Rule 330.7009
Your civil rights are protected even though you are receiving mental health services. You have the right
to an education, the right to vote*, and the right not to be discriminated against because of: age, color,
height, national origin, sex, religion, race, weight or due to a physical or mental disability.
* Information about registration and voting may be obtained from the Office of Recipient Rights
If you (or someone on your behalf) believe that you have been discriminated against, a complaint may
be filed with the Office of Recipient Rights at any time, even when you are no longer receiving services.
Additionally, you may file a discrimination complaint with either the:
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Michigan Department of Civil Rights
110 West Michigan Avenue, Lansing, Michigan 48913
VOICE: 1-800-482-3604
U.S. Department of Health and Human Services, Office for Civil Rights
233 N. Michigan Ave., Suite 240, Chicago, IL 60601
VOICE 1-312-886-2359 FAX 1-312-886-1807 TDD 1-312-353-5693
To file with either of these agencies you must write to them within 180 days of the time the alleged
discrimination occurred. If you are still not satisfied, you may also sue in the State Circuit Court or Federal
District Court.
As a person with a mental disability, you may have additional protections under the following laws:
Americans with Disabilities Act (ADA)
Fair Housing Amendments Act
Civil Rights of Institutionalized Persons Act
Individuals with Disabilities Education Act (IDEA)
Rehabilitation Act, Section 504
Michigan Disability Civil Rights Act
Title II of the Americans with Disabilities Act (ADA)
Title II of the ADA prohibits discrimination on the basis of disability by public entities. It states that
people with disabilities cannot be denied services or participation in programs or activities that are
available to people without disabilities. If you feel your rights under Title II have been violated by state
or local governmental agencies, you may file a complaint with the Department of Justice. This must be
done within 180 days from the date of discrimination. For more information, or to file a complaint,
contact the U.S. Department of Justice, 950 Pennsylvania Avenue, NW Civil Rights Division, Disability
Rights Section – 1425 NYAV, Washington, D.C. 20530. You may also call VOICE: 1-800-514-0301 or TTY:
1-800-514-0383 or send an email to: [email protected].
Title III of the Americans with Disabilities Act (ADA)
Title III of the ADA requires that public accommodations such as restaurants, hotels, grocery stores,
retail stores, etc., as well as privately owned transportation systems, be accessible to individuals with
disabilities. If you feel your rights under Title II have been violated you may file a complaint with the
Department of Justice. In certain circumstances cases may be referred to a mediation program
sponsored by the Department. See the address and phone numbers given above. Title III may also be
enforced through a private lawsuit.
Fair Housing Amendments Act
The Fair Housing Amendments Act prohibits discrimination by direct providers of housing, such as
landlords and real estate companies as well as other entities, such as municipalities, banks or other
lending institutions and homeowners’ insurance companies. If you feel your rights under this Act have
been violated, you may file a complaint with the U.S. Department of Housing and Urban Development.
For more information on filing a complaint, contact the Department of Housing and Urban
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Development, Chicago Regional Office, Ralph Metcalfe Federal Building, 77 West Jackson Boulevard,
Chicago, Illinois 60604, VOICE: 1-312-353-5680, or TTY: 1-312- 353-7143.
Civil Rights of Institutionalized Persons Act
Under the Civil Rights of Institutionalized Persons Act, the Attorney General may initiate a civil rights
lawsuit when there is reasonable cause to believe that the conditions are significant enough to subject
residents to serious harm and they are part of a pattern or practice of denying residents' constitutional
or federal rights including Title II of the ADA and Section 504 of the Rehabilitation Act. To bring a matter
to the attention of the Department of Justice, contact the Special Litigation Section, Civil Rights Division,
U.S. Department of Justice, 950 Pennsylvania Ave NW, Washington, D.C. 20530, VOICE/TTY: 1-877-2185228 or send an email to: [email protected].
Individuals with Disabilities Education Act
Under the Individuals with Disabilities Education Act, if a parent disagrees with the proposed IEP, he/she
can request a due process hearing from the Michigan Department of Education. To contact the
Michigan Special Education Mediation Program (MSEMP) call 1-800-RESOLVE, send an email to
[email protected], or complete an online request on the MSEMP website at: https://msemp.cenmi.org.
The state agency's decision can also be appealed to a state or federal court. For more information about
this act and your rights, contact the Office of Special Education and Rehabilitative Services, U.S.
Department of Education, 400 Maryland Ave., SW, Washington, DC 20202-7100 or you may call VOICE:
1-202- 245-7468.
Section 504 of the Rehabilitation Act
Under Section 504 of the Rehabilitation Act, no qualified individual with a disability in the United States
shall be excluded from, denied the benefits of, or be subject to discrimination under any program or
activity that either receives federal financial assistance or is conducted by any executive agency or the
U.S. Postal Service. If you feel that you have been discriminated against by an agency receiving federal
money based on disability, you can file a 504 complaint with an appropriate agency by contacting
contact Civil Rights Division NYAV, U.S. Department of Justice, 950 Pennsylvania Ave NW, Disability
Rights Section, Washington, D.C. 20530. You may also call VOICE: 1-800-514-0301 or TTY: 1-800-5140383.
Michigan's Elliott Larsen Act and Michigan Handicapper Civil Rights Act.
If you are a recipient who believes that you have been discriminated against in your job because of your
race, gender, marital status, etc., you are protected under Michigan's Elliott Larsen Act. If you believe
you have been discriminated against based upon disability, you are protected under the Michigan
Handicapper Civil Rights Act. For information regarding either of these laws, or to file a complaint,
contact the Michigan Department of Civil Rights, 110 W. Michigan Avenue, Lansing, Michigan 48913,
VOICE: 1-800-482-3604, TTY 1-877-878-8464 or send an email to [email protected].
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SECTION II: TREATMENT RIGHTS IN ALL MENTAL HEALTH SETTINGS
Treatment and Support
Mental Health Code Section 705, 707- 719, 744; Administrative Rule 7029, 7135
You have the right:
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To be told why you are being treated and what your treatment is.
To participate in the development of your plan of service and to involve family members, friends,
advocates, and professionals of your choice in the development process. Justification for the
exclusion of a person of your choice must be documented in your case record.
To have your plan of service developed within seven days of commencement of services or before
discharge or release if you are hospitalized less than seven days.
To choose, within certain limitations, the physician or other mental health professionals to provide
services for you, if you receive services from a community mental health services program or a
licensed hospital.
To be informed of your progress, both orally and in writing, at reasonable intervals and in a manner
appropriate to your condition.
To not have surgery unless consent is obtained from at least one of the following:
You, if you are over 18 years old and do not have a guardian for medical purposes,
If you are under 18 years of age, your parent with legal and physical custody,
Your guardian who has legal authority to consent to surgery,
A representative authorized to give consent under a durable power of attorney or other
advance directive,
OR
If your life is threatened and there is not time to obtain consent, surgery may be performed
without consent after the medical necessity for the procedure has been documented and the
documentation has been entered into your record.
Surgery is necessary, no appropriate person can be found to give consent, and the probate court
consents to the surgery.
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To be given notice of available family planning and health information services and, if you ask, to
have staff provide referral assistance to providers of these services. Your receipt of mental health
services does not depend in any way on requesting or not requesting family planning or health
information services
To have staff help you get treatment by spiritual means if you ask for it.
To receive treatment in a place where you have as much freedom as your condition allows.
To not have electroconvulsive therapy (ECT) or other procedures intended to produce convulsions
or coma, unless consent is obtained from:
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You, if you are over 18 years old and do not have a guardian for medical purposes,
If you are under 18 years of age, your parent with legal and physical custody,
Your guardian who has legal authority to consent to ECT,
A representative specifically authorized to consent to ECT under a durable power of attorney or
other advance directive.

To receive a second opinion if you have been denied services by making a request to the Executive
Director of the Community Mental Health Services Program.
Person-Centered Planning
Mental Health Code Section 712
The Mental Health Code requires a person-centered approach to the planning, selection, and delivery of
the supports, services, and/or treatment you receive from the public mental health system (community
mental health programs, psychiatric hospitals, and mental health service providers under contract to
any of these).
What is person-centered planning?
Person-centered planning means the treatment you receive will be made up of activities which you think
will help you, which you assist in developing, and which meet your goals. This process will determine the
supports you want or need to achieve your desired future. The staff involved in your treatment will
encourage feedback from you about these supports, the progress you have made, and any changes you
think would make your treatment more effective.
There are four basic parts in the person-centered process:

Identifying the future you desire.
It is up to you to choose the individuals who will help identify your future and help you plan for
it. You will be a part of deciding what information is, or is not, shared at the meeting. You will be
able to choose, within reason, the times and place you want to have meetings to plan your
treatment, to decide the content of the meetings and how long they will be.

Planning the future you desire.
Meetings which are held to plan for your future will attempt to discover what is important to
you, to share information about your abilities, strengths, and skills, to learn about your needs
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and to decide which of your desired goals will be achieved in the short term and which will need
to be long-term. Then, you and the support team will determine the strategies for achieving
these goals.

Finding the supports and services it will take to achieve your desired future.
You will be able to use the resources in your network of family, friends, your community, and
the public mental health system which might be available to assist in achieving your desired
outcomes. You will be able to choose, from available resources, the supports and services to be
delivered, and help decide who will do what, when, and how.

Getting regular feedback on your treatment.
It is important for you to receive feedback on your progress. This should be done by informally,
and regularly, discussing with your case manager (supports coordinator) how supports and
services are being delivered, your satisfaction with their delivery, and progress toward your
desired outcomes. The information you provide should be used to make any necessary changes
in the supports and services you receive.
You should also have the opportunity to formally express your opinion about supports and services you
receive so that improvements in service delivery can be made for everyone.
In addition, you always have the right to make formal complaints about how your supports and services
were delivered or about any of the people who might have provided them. Contact your Rights
Officer/Advisor if you would like to do this.
Questions You May Want To Ask About Person-Centered Planning
Who must attend the person-centered planning meeting?
You, and your legal representative (a parent if you are a minor or guardian) and your supports
coordinator (case manager).
Who also might be included?
You may want to invite family members, co-workers, friends, a teacher, coach, staff, and other
people who know you well and with whom you feel comfortable sharing personal information.
Your supports coordinator (case manager) may also suggest inviting a nurse, physical therapist,
or direct care staff, who has information to help in planning and decision making.
What kinds of outcomes are discussed?
"Outcomes" may include:
Having positive relationships with family members,
Participating in community activities and events,
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Doing what you find meaningful and productive with your day, (such as going to school,
work, volunteering),
Living in a place alone, or having assistance from people you choose.
Are there limits to person-centered planning?
Person-centered planning does not guarantee that the supports, services, and/or treatment nor
the amount of them you might like to have can be provided by the public mental health system.
What is actually provided by the public mental health system will depend upon the available
resources (such as funding and staffing), rules and regulations that govern the program or
funding system, and/or the judgment of the program administrator(s) as to feasibility,
appropriateness, and safety of such support, service, or treatment.
SECTION III: YOUR RIGHTS WHEN YOU ARE BEING ADMITTED OR
DISCHARGED FROM A PSYCHIATRIC HOSPITAL OR UNIT
Voluntary Admission Process
Mental Health Code Sections 410-420
If you are admitted to a psychiatric hospital or unit on a VOLUNTARY BASIS (you admit yourself), or you
are admitted by application of your guardian (with your agreement) you have the right:

To give written notice of your intent to leave the hospital.
After you put your request in writing, you must be discharged within three (3) days
(excluding Sunday and holidays). However, if the hospital director determines you require
treatment and petitions the court for your involuntary admission you must remain in the
hospital until a determination is made about your treatment by the court.
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To be discharged when treatment is complete or when you no longer need the services.
To request a second opinion if the community mental health services program pre-admission
screening unit does not think you need to go into the hospital.
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Involuntary Admission Process
Mental Health Code Sections 423-450; 498
If you are INVOLUNTARILY ADMITTED (COURT ORDERED) to a psychiatric hospital or unit, you have the
following rights:
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To make at least two phone calls.
To a copy of the application or petition saying you require treatment and to copies of reports by the
doctors who examine you.
To have a physical and mental examination within 24 hours after you are admitted, and again at
least once a year.
To a written statement explaining that you will be examined by a psychiatrist within 24 hours after
you are admitted.
To a written statement explaining your rights.
To a full court hearing.
To be represented by an attorney.
To be present at the hearing.
To a jury trial.
To an independent clinical examination.
To have staff, if you wish, notify your family of your admission to the hospital.
If the police take you into protective custody and bring you to a preadmission screening unit, to
have staff of that unit complete their examination of you within two (2) hours unless there is a
documented medical reason for the delay.
To be examined by two doctors or by a psychologist and a psychiatrist to determine whether you
need to be admitted. One of the examinations must be by a psychiatrist and the first examination
may be done before you are brought to the hospital.
To refuse medication before your court hearing unless a physician decides you need it to prevent
you from physically hurting yourself or others or if your life is in danger. If you agree to medication
or treatment before the court hearing, this does not mean that you are agreeing to the
hospitalization.
To have an independent medical examination before your full court hearing.
Within 72 hours (this does not include Sundays and holidays) after a petition and clinical certification
have been filed with the court, you have:
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The right to meet with legal counsel,
The right to meet with a treatment team member assigned by the hospital director,
The right to meet with a designated community mental health worker,
The right to designate an individual of your choice to meet with you and the people indicated
above for the purpose of informing you of:
The proposed plan of service in the hospital.
The proposed plan of service in the community.
The nature and possible consequences of the involuntary hospitalization process.
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
The right to request that your court hearing be “deferred” (delayed) temporarily (60 or 90 days).
You will be treated as a voluntary patient during this time; however, you have the right to demand
a hearing at any time during the “deferral” period.
As an involuntary (court-ordered) recipient, YOU DO NOT HAVE THE RIGHT TO REFUSE TREATMENT. However,
you do have the right to ask questions about your treatment, participate in the development of your
plan of service, and discuss it with your doctor or other mental health professionals. If you think your
treatment is not helping, you may ask for a review of your treatment plan.
Questions You May Want to Ask About Your Medication
If you are given medication by your doctor you will need to take it according to
his/her instructions. Listed below are some questions you may want to ask of the
doctor or nurse so that you can have the information you need to make it as
effective as possible.
Why do I have to take this medicine?
What will happen if I do not take it?
Can I be treated without medication?
Before I begin taking any medicine or even if I am not taking medicine, can I have a second opinion?
What is the name of the medicine prescribed for me?
How is it supposed to make me feel? What are the side effects of the medicine? Will it affect any
other medical or physical problems I have?
Are there side effects I should report immediately?
Is it similar to or different from the medicine I was taking before this?
How much should I take? How many times a day? What time of day? Before or after meals?
What would happen if I took too much?
Is it all right if I drink alcohol or beer when taking this medicine? Is there any food or other drink I
should avoid?
Are there other medicines I should avoid when taking this medicine?
Will this medicine affect my interest and/or my ability to participate in sex?
How long will I need to take this medicine?
If I take this medicine for a long time, what can it do to me?
What is tardive dyskinesia (TD)? Can I get TD from taking this medicine? Can something be done to
avoid this?
For women in child bearing years:
Will this affect my menstrual periods?
Should I take birth control pills while taking this medicine?
If I get pregnant while taking this medicine, could it have any effect on my baby?
Should I take it while nursing?
Should I drive or operate machinery while taking this medicine?
Is there anything else I should know about this medicine?
How often will you review with me what the medicine is doing?
How soon will I need to take this medicine?
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Court Hearings
Mental Health Code Sections 452; 463
If you are admitted to the hospital involuntarily, you have the following rights regarding court hearings:

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To have your court hearing promptly, but not more than seven days (this does not include Sundays
or holidays) after the court receives the application (petition).
To be present at all court hearings. During this hearing, you have the right to be represented by an
attorney. If you cannot afford an attorney, the court will appoint one for you. Your attorney must
consult with you, in person, at least 24 hours before the time set for your court hearing. (You may
choose to waive the right to attend your hearing by signing a waiver witnessed by your legal counsel
and filed with the court.)
To demand a jury trial.
To present documents and witnesses and to cross examine witnesses.
To obtain, at public expense if necessary, an independent clinical evaluation by a physician,
psychiatrist, or licensed psychologist of your choice. (You must request this before the first
scheduled hearing or at the first scheduled hearing before the first witness has been sworn.)
To a copy of the court order.
Periodic Review
Mental Health Code Sections 482; 485a
If you have a court order for continuing involuntary treatment, you have the right to regular, adequate,
and prompt reviews of your status. These reviews must be done six (6) months from the date of the
court order and every six (6) months from there on.
Results of these reviews must be provided to you within five days from the time they are made part of
your record and you must be informed of your right to petition for discharge.
If you do petition for discharge following the periodic review, you have the right to a hearing. In addition
to that hearing, you may petition the court for a discharge hearing once within each 12 month period
from the date of the original order. If, after any of these hearings, the court determines that you no
longer require treatment, you will be discharged.
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Rights of Minors
Mental Health Code Section 498m
If you are a minor, 14 years of age or older (between 14 and 17), you have the right to ask for, and
receive, outpatient mental health services (not including psychotropic medication or pregnancy
termination referral services) without the consent or knowledge of your parent or guardian. These
services are limited to 12 sessions or 4 months for each request.
If you are a minor 14 years of age or older (between 14 and 17), you may write to the court within 30
days of your admission to object to your being hospitalized. You may do so again within 30 days from
the time you receive a written review from the clinical staff regarding your need for continued
hospitalization.
If you are a minor of any age and have been hospitalized for more than 7 days, you may inform a
hospital staff person of your desire to object to your hospitalization. Someone from the staff is required
to assist you in properly filing your objection to the hospitalization. If no one does this, then ask to see
the Rights Advisor who will help get someone to assist you.
If you are re-hospitalized for longer than 10 days under a combined hospitalization/alternative
treatment order, you must be notified of your right to file an objection to the hospitalization. If you do
object, the court must schedule a hearing to determine whether you continue to be a person requiring
treatment.
SECTION IV: YOUR RIGHTS WHEN YOU ARE LIVING IN
A RESIDENTIAL OR INPATIENT SETTING
The Mental Health Code guarantees that recipients receiving inpatient or residential services will be
assured that some basic rights are protected. These rights may be limited due to the nature of your
treatment. If such limitations are imposed, they must be agreed to in the plan of service by you or your
legal representative. General restrictions that apply to everyone (such as visiting hours, property you
may not have, or times the telephone may be used) can be established by a residence or unit. These
restrictions must be posted in a place where they can be easily seen.
Mail
Mental Health Code Section 726
You have the right to receive and send mail without anyone else opening or reading it. If you have no
income, and if you ask, you will be given writing materials and a reasonable number of stamps.
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Telephone
Mental Health Code Section 726
You have the right to talk on the phone. If you have no income, a reasonable amount of funds will be
provided so that you can use the telephone.
Visitors
Mental Health Code Section 715, 726, 748; Administrative Rule 7135
You have the right to see visitors of your choice. You can ask to see your own doctor (if you have one)
or visit with your minister, priest, rabbi, or spiritual counselor at reasonable times. You have the right to
talk with your attorney, a court, or others, about legal matters without any limitations and at any time.
Entertainment Materials, Information and News
Mental Health Code Section 704; Administrative Rule 7139
You have the right to watch television, have a newspaper provided, buy magazines, and books of your
own choice, unless limited by your plan of service or as generally restricted by program rules.
Religion
Mental Health Code Section 704
You have the right to practice your religion or faith. You cannot be forced to go to a religious event if
you do not want to, nor can you be required to listen to or watch religious programs on radio or TV.
Personal Property
Mental Health Code Section 728; Administrative Rule 7009
You have the right to:
 Wear your own clothes and keep your own things.
 Inspect your personal property at reasonable times.
 Have a receipt given to you, and to a person you designate, for your property held by the
facility. Unless it is illegal, this property must be returned to you when you are discharged
 Have a reasonable amount of space to store your personal belongings.
 Not have your belongings searched unless this is part of your plan of service or unless there is a
good reason; to watch if your belongings are searched; and to have the reason for the search
written in your record.
Your plan of service may further limit this right for the following reasons:
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To protect property you may have brought with you from theft, loss, or destruction.
To prevent you from physically hurting yourself or others.
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You, and your legal representative, should be told the reason for the limitation and the date it expires.
Money
Mental Health Code Sections 730-736
If you are in a state-operated psychiatric hospital, you have the right to:
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Be paid for work you agree to do if you are offered work. However, you will not be paid for personal
housekeeping chores (such as making your own bed) or work which is part of a small group living
arrangement.
Not have more than half of any money you earn used to pay for your treatment.
Have your money kept in an account in your name at the facility and have easy and reasonable
access to that account.
To spend your money as you want. Facility rules may limit the amount of money you can have on
you at any one time.
Have money in the account given to you when you are discharged.
These rights may be limited


If the U.S. government says you need someone to handle money you receive from Social Security
and has assigned you a representative payee, or
If you have a conservator or guardian who has the authority to limit how you spend your money.
Freedom of Movement
Mental Health Code Sections 740, 742, 744
Freedom of movement is a right, not a privilege. This right cannot be limited or restricted more than is
necessary to provide mental health services to you, to prevent you from injuring yourself or others, or to
prevent substantial property damage. If you are admitted by order of a criminal court or are transferred
from a jail or prison, appropriate security precautions may be taken. If there are limitations on your
freedom of movement, the expected length and the reasons for them must be written into your record.
The limitations must be removed when the reasons for them no longer exist.
If you are in a psychiatric hospital or licensed child caring institution, you may only be put in a locked
room (seclusion):
 To keep you from physically hurting others.
 To keep you from causing substantial property damage.
If you are a resident in an inpatient or residential setting, you may only be physically restrained if facility
licensure rules allow and:
 To keep you from physically hurting yourself or others.
 To keep you from causing substantial property damage.
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SECTION V: RIGHTS OF PERSONS WHO ARE RECEIVING TREATMENT
UNDER FORENSIC PROVISIONS OF THE MENTAL HEALTH CODE
Incompetent to Stand Trial (IST)
Mental Health Code Section 330.2020 -.2044
If you are admitted to a hospital on an IST (Incompetent to Stand Trial) Order you are under the
jurisdiction of the criminal court, not the probate court system. The IST order means that the court has
determined that, due to your mental condition, you are unable to understanding the nature and object
of the proceedings against you or of assisting in your defense in a rational manner. This order may be
valid for up to 15 months during which time you will receive psychiatric treatment. Reevaluation of your
competence will be done by your treating psychiatrist every 90 days and a report will be submitted to
the criminal court.
Not Guilty by Reason of Insanity (NGRI)
Mental Health Code Section 330.2050
If you are found to be Not Guilty of a criminal charge due to reasons of insanity (Not Guilty by Reason of
Insanity or NGRI), you will be sent to the Center for Forensic Psychiatry, for a period of not more than 60
days, so that you can be evaluated and a determination made as to whether you are a person who
requires mental health treatment. If the Center determines that you do require mental health
treatment, the court may direct the prosecutor to file a petition for involuntary hospitalization. If this
occurs, you will have a hearing in a probate court to determine if you will be involuntarily hospitalized
(See Section III of this book). You will have to stay at the Forensic Center until the probate court hearing.
If a petition for involuntary hospitalization is not filed, the prosecutor will notify the Center and you shall
be discharged.
SECTION VI: THE RECIPIENT RIGHTS COMPLAINT
AND APPEAL PROCESS
Filing a Recipient Rights Complaint
Mental Health Code Section 776
If you believe that any right listed in this booklet has been violated, you, or someone on your behalf,
should file a recipient rights complaint. You may do this by calling or visiting the Rights Office, or by
completing a recipient rights complaint form and returning it to the Rights Office. Copies of the rights
complaint form are available wherever you receive services, from your local rights office, or online at
the Office of Recipient Rights website: www.michigan.gov/recipientrights; click on the link Recipient
Rights Complaint Form. The name and telephone number of the Rights Officer/Advisor for this agency
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can be found on the back of this booklet and will be clearly posted in the place you are receiving
treatment.
Your complaint needs to contain:



A statement telling the Rights Office what you are complaining about;
What right(s) you think have been violated;
What you think will resolve your complaint.
If you want help writing your complaint your Rights Officer/Advisor can assist you; you may also contact
one of the advocacy organization listed in Section VII of this book for assistance.
Investigating Your Complaint
Mental Health Code Section 776
Within five (5) business days after receiving your complaint, the Rights Office will send you a letter
which tells you that your complaint was received as well as a copy of the complaint. This letter will also
tell you whether your complaint is going to be investigated.
If the Rights Officer/Advisor investigates your complaint, he/she will decide if your rights have been
violated and, if necessary, will recommend appropriate action to correct the violation. The Rights
Officer/Advisor should finish investigating your complaint no later than 90 days after it was received.
You will get a written status report every 30 days until completion of the investigation.
When the investigation is complete, the Rights Officer/ Advisor will submit an Investigative Report to the
Agency Director. Within 10 business days after receiving this report, he/she will provide you with a
written Summary Report.
The Summary Report will tell you about the investigation, let you know if the Rights Office determined
your rights were violated or not, and tell you about any recommendations made by the Rights Office. If
it is determined that there was a rights violation, this report will also tell you what action the Director
has taken, or will take, to resolve your complaint. It will also provide you with information regarding the
appeal process.
Appeal Rights
Mental Health Code Sections 784-786
Local Appeals Committee Review
If you are not satisfied with the findings of the Rights Office, with the action taken (or the proposed
action indicated), or if you think the Rights Office did not start, or complete, the investigation in a timely
manner, you have the right to file an appeal. An appeal must be in writing and received by the local
appeals committee within 45 days. Information on where to file your appeal will be given to you in the
Summary Report that you receive after your complaint is investigated. If you want help writing your
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appeal, your Rights Officer/Advisor can assist you; you may also contact one of the advocacy
organization listed in Section VII of this book for assistance.
Within five (5) business days after receiving your appeal, the appeals committee will review it to see if it
meets the requirements, and will notify you, in writing, whether or not your appeal was accepted. This
committee then has 25 days to review the case file provided by the Rights Office and make a decision on
your appeal. They may ask you to provide more information. You will receive their written decision no
later than ten days after their meeting.
Second Level Appeal – Findings of the Rights Office
If your appeal was based upon your belief that the investigative findings of the Rights Office were not
consistent with the facts or relevant laws, rules, policies, or guidelines, and you are not satisfied with the
decision of the local appeals committee, you have 45 more days to file a written appeal to the next level.
This should be sent to: MDCH Level 2 Appeals, P.O. Box 30807 Lansing, MI 48909. Information on this
process will be provided in the response from the local appeals committee.
If you are not satisfied with the answer from the Level 2 Appeal, you may file an appeal with the Circuit
Court in the county where you live (or with the Ingham County Circuit Court). You only have 21 days to
do this and may need to hire an attorney to help you. Your appeal to the Circuit Court is based on the
entire record of your appeal which was put together by the Second Level Appeal reviewer.
Second Level Appeal – Action Taken
There is no second level of appeal if your appeal to the local committee had to do with the action taken,
or not taken, as a result of your complaint. In this case, if you are not satisfied with the decision of the
local appeals committee, you may file a new complaint against the person (the Director of the Agency
from which you receive services) who issued the Summary Report.
Mediation
Mental Health Code Section 788
After the investigation of the Rights Office is finished, you have the right to request mediation of your
dispute. Mediation is voluntary for all parties. The mediation process involves a meeting between you, a
representative of the agency providing your services and a person who is trained to help resolve
complaints. If you reach an agreement, you will have to sign a statement which states you and the
agency will follow the agreement. During the mediation process, time frames for appeals stop.
Therefore, if mediation is not successful, you will still have the right to pursue an appeal. If you wish to
request mediation, contact your Rights Office.
02/2013
Page 19
SECTION VII: ADVISORY GROUPS AND ORGANIZATIONS
THAT MAY ALSO ASSIST YOU
The following groups and organizations are available to assist you in protecting your rights as a recipient of mental
health services:
Association for Children's Mental Health (ACMH)
State Office
6017 W. St. Joseph Hwy., Suite #200, Lansing,
Michigan 48917
(517) 372-4016
Fax: (517) 372-4032
Parent Line: (888) ACMH-KID (226-4543)
http://www.acmh-mi.org/
The ARC - Michigan
1325 S. Washington Ave., Lansing, MI 48910-1652
(800) 292-7851 or (517) 487-5426
Fax: (517) 487-0303
http://www.arcmi.org/
Michigan Disability Rights Coalition
3498 East Lake Lansing Road, Suite #100, East
Lansing, MI 48823
In Michigan: (800) 760-4600 or (517) 333-2477
Fax (517) 333-2677
http://www.copower.org/
Michigan Protection & Advocacy Service, Inc.
4095 Legacy Parkway, Suite #300, Lansing, MI 48911
(800) 288-5923 or (517) 487-1755 (Voice or TTY)
Fax: (517) 487-0827
http://www.mpas.org/
National Alliance on Mental Illness (NAMI) Michigan
921 N. Washington
Lansing, MI 48906
1 (800) 331-4264
http://www.namimi.org/
United Cerebral Palsy of Michigan – UCP Michigan
4970 Northwind Dr., Suite #102, East Lansing, MI,
48823
(800) 828-2714 (Michigan only) or (517) 203-1200
Fax: (517) 203-1203
http://www.ucp.org/ucp_local.cfm/87
02/2013
Page 20
To learn more about your rights,
ask your Rights Officer/Advisor.
DCH-0085
(rev 02/13)
Produced by:
Michigan Department of Community Health
Office of Recipient Rights
Lewis Cass Building
Lansing, MI 48913
Authorized by:
Michigan Mental Health Code
P.A. 258 of 1974, as amended
MDCH is an equal opportunity employer,
service, and programs provider
General Authorization for Use or
Disclosure of Health Information
General Authorization for Use or
Disclosure of Health Information
Completion of this document authorizes the disclosure and/or use of individually identifiable health information, consistent with applicable
State and Federal law. Failure to provide all information requested may invalidate this Authorization.
Date of Request: _______________
Medical Record Number (if known) __________________________
1. Protected health information may be used or disclosed regarding the following person:
Name: (Last)_____________________________________ (First)___________________(M.I.)________ Date Of Birth __________
Completion of this document authorizes the disclosure and/or use of individually identifiable health information, consistent with applicable
State and Federal law. Failure to provide all information requested may invalidate this Authorization.
Date of Request: _______________
1. Protected health information may be used or disclosed regarding the following person:
Name: (Last)_____________________________________ (First)___________________(M.I.)________ Date Of Birth __________
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
Telephone: (day) ( ____ ) ____________
(eve) ( ____ ) ____________
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
Social Security #: ________________________ (Optional)
Telephone: (day) ( ____ ) ____________
2. The following person or facility is authorized to disclose my Protected Health Information
Adult Partial Hospitalization Program
Name of Person or Facility____________________________________________________________
(Phone) ( ____ ) ____________
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
3. The following person or facility is authorized to receive my Protected Health Information
Name of Person or Facility:____________________________________________________________ (Phone) ( ____ ) ____________
4. My health information will be used or disclosed for the following purpose(s) (ex: Marketing Activities, Fundraising Activities,
Employment Determination, Continued Care, Legal, Claims etc.): _______________________________________________________
5. This Authorization applies to the following information*:
q The following records or types of health information (specify date(s) of service):________________________________________
q Discharge Summary
q X-ray Film (avail from Radiology Dept)
q Consultation Report
q X-ray Report
q Cardiopulmonary/EKG Report
q Multidisciplinary Notes
q Physical Therapy Notes
q Nursing Notes
q Physician Progress Notes
q Operative Report
q Billing Information (available
q Emergency Room Report
q Laboratory and Pathology Report
from Patient Financial Services)
q History and Physical
q Other (Please Specify)______________________________________________
Social Security #: ________________________ (Optional)
Name of Person or Facility____________________________________________________________ (Phone) ( ____ ) ____________
3. The following person or facility is authorized to receive my Protected Health Information
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
(eve) ( ____ ) ____________
2. The following person or facility is authorized to disclose my Protected Health Information
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
Members:
Name of Person or Facility:__Family
__________________________________________________________
(Phone) ( ____ ) ____________
Medical Record Number (if known) __________________________
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
4. My health information will be used or disclosed for the following purpose(s) (ex: Marketing Activities, Fundraising Activities,
Employment Determination, Continued Care, Legal, Claims etc.): _______________________________________________________
6. Patient Only
q Paper
qElectronic
5. This Authorization applies to the following information*:
q The following records or types of health information (specify date(s) of service):________________________________________
q Discharge Summary
q X-ray Film (avail from Radiology Dept)
q Consultation Report
q X-ray Report
q Cardiopulmonary/EKG Report
q Multidisciplinary Notes
q Physical Therapy Notes
q Nursing Notes
q Physician Progress Notes
q Operative Report
q Billing Information (available
q Emergency Room Report
q Laboratory and Pathology Report
from Patient Financial Services)
q History and Physical
q Other (Please Specify)______________________________________________
* Information about the diagnosis and testing for HIV, AIDS, and ARC; Information about alcohol and drug treatment; and Information about mental
health services and social services (including communications made to a social worker or mental health professional) may be contained in these
documents and will be disclosed if it is part of the requested records. If you do not wish to have this information disclosed, please initial here:_______ .
* Information about the diagnosis and testing for HIV, AIDS, and ARC; Information about alcohol and drug treatment; and Information about mental
health services and social services (including communications made to a social worker or mental health professional) may be contained in these
documents and will be disclosed if it is part of the requested records. If you do not wish to have this information disclosed, please initial here:_______ .
7. This Authorization expires:__________________________________________ (if no expiration date or event is listed, this
authorization will expire 90 days after the date of request or at the completion of the request, whichever is earlier)
6. This Authorization expires:__________________________________________ (if no expiration date or event is listed, this
authorization will expire 90 days after the date of request or at the completion of the request, whichever is earlier)
q If this box is checked, I understand that the person or facility requesting my authorization will receive direct or indirect payment for the uses and
disclosures I have authorized.
__________________________________________________ Signature of Patient or Personal Representative
__________________________________________________
Relationship to the patient (if Personal Representative)
For Office Use Only: Identity and Authority Validated: __________ (initials)
Date Request Received ______________
Notice Of Federal And State Laws Regarding Further Disclosure To The Person Or Organization Receiving Information“This information may have
been disclosed to you from records whose confidentiality is protected by Federal and State Laws. Federal regulations (42 CFR, part 2) and State law (Public Act 258, Chapter
7, section 748) prohibit you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such
regulations. A general authorization for the release of medical or other information is NOT sufficient for this purpose.”
*AA1008*
Please see Pg. 2 for information on your rights and for mailing information
1
292348 / 09006 R 8/12 (M)D
q If this box is checked, I understand that the person or facility requesting my authorization will receive direct or indirect payment for the uses and
disclosures I have authorized.
__________________________________________________ Signature of Patient or Personal Representative
__________________________________________________
Relationship to the patient (if Personal Representative)
For Office Use Only: Identity and Authority Validated: __________ (initials)
Date Request Received ______________
Notice Of Federal And State Laws Regarding Further Disclosure To The Person Or Organization Receiving Information“This information may have
been disclosed to you from records whose confidentiality is protected by Federal and State Laws. Federal regulations (42 CFR, part 2) and State law (Public Act 258, Chapter
7, section 748) prohibit you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such
regulations. A general authorization for the release of medical or other information is NOT sufficient for this purpose.”
*AA1008*
Please see Pg. 2 for information on your rights and for mailing information
1
292348 / 09006 R 9/04 (M)D
YOUR RIGHTS:
YOUR RIGHTS:
I understand that if the person or entity that receives the information is not a health care provider or health plan covered
by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these
regulations. An exception for registered substance abuse and chemical dependency clients applies. See notice below.
I understand that if the person or entity that receives the information is not a health care provider or health plan covered
by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these
regulations. An exception for registered substance abuse and chemical dependency clients applies. See notice below.
I understand that I may revoke this limited Authorization in writing at any time at the address found below, except to the
extent that action has been taken in reliance on this Authorization. This Authorization is in effect until revoked by me or
until it expires under applicable laws. An exception for registered chemical dependency and substance abuse patients who
are involved in the Criminal Justice System when the consent is a condition of parole, probation or release from confinement
applies. In these cases this consent may not be revoked at any time unless there has been a formal and effective termination or
revocation of such release from confinement, probation or parole.
I understand that I may revoke this limited Authorization in writing at any time at the address found below, except to the
extent that action has been taken in reliance on this Authorization. This Authorization is in effect until revoked by me or
until it expires under applicable laws. An exception for registered chemical dependency and substance abuse patients who
are involved in the Criminal Justice System when the consent is a condition of parole, probation or release from confinement
applies. In these cases this consent may not be revoked at any time unless there has been a formal and effective termination or
revocation of such release from confinement, probation or parole.
This form should be mailed to:
qSaint Joseph Mercy Health System
Health Information Services Department
5301 East Huron River Drive
PO Box 995
Ann Arbor, MI, 48106-0995
This form should be mailed to:
qSaint Joseph Mercy Health System
Health Information Services Department
5301 East Huron River Drive
PO Box 995
Ann Arbor, MI, 48106-0995
I understand that I may refuse to sign this Authorization and that my refusal to sign will not affect the use or disclosure of
my protected health information for purposes of treatment, payment or health care operations. I may inspect or copy any
information used/disclosed under this Authorization.
qSt. Joseph Mercy Livingston Hospital
Health Information Services Department
620 Byron Road
Howell, MI 48843
I understand that I may refuse to sign this Authorization and that my refusal to sign will not affect the use or disclosure of
my protected health information for purposes of treatment, payment or health care operations. I may inspect or copy any
information used/disclosed under this Authorization.
q Other______________________________________________________________________________________________
q__________________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
REVOCATION OF THIS AUTHORIZATION
____________________________________________________________________________________________
____________________________________________________________________________________________
REVOCATION OF THIS AUTHORIZATION
I hereby revoke the authorization made on _____________.
I hereby revoke the authorization made on _____________.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
______________________________________________________
Signature of Patient or Representative
__________________________
Date/Time
__________________________________________________________________________________________________
__________________________________________________________________________________________________
______________________________________________________
Signature of Patient or Representative
__________________________________________________________
Relationship to the patient (if Personal Representative)
__________________________________________________________
Relationship to the patient (if Personal Representative)
This revocation should be mailed to:
Saint Joseph Mercy Health System
Health Information Services Department
5301 East Huron River Drive
PO Box 995
Ann Arbor, MI, 48106-0995
This revocation should be mailed to:
Saint Joseph Mercy Health System
Health Information Services Department
5301 East Huron River Drive
PO Box 995
Ann Arbor, MI, 48106-0995
2
2
__________________________
Date/Time
General Authorization for Use or
Disclosure of Health Information
General Authorization for Use or
Disclosure of Health Information
Completion of this document authorizes the disclosure and/or use of individually identifiable health information, consistent with applicable
State and Federal law. Failure to provide all information requested may invalidate this Authorization.
Date of Request: _______________
Medical Record Number (if known) __________________________
1. Protected health information may be used or disclosed regarding the following person:
Name: (Last)_____________________________________ (First)___________________(M.I.)________ Date Of Birth __________
Completion of this document authorizes the disclosure and/or use of individually identifiable health information, consistent with applicable
State and Federal law. Failure to provide all information requested may invalidate this Authorization.
Date of Request: _______________
1. Protected health information may be used or disclosed regarding the following person:
Name: (Last)_____________________________________ (First)___________________(M.I.)________ Date Of Birth __________
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
Telephone: (day) ( ____ ) ____________
(eve) ( ____ ) ____________
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
Social Security #: ________________________ (Optional)
Telephone: (day) ( ____ ) ____________
2. The following person or facility is authorized to disclose my Protected Health Information
Adult Partial Hospitalization Program
Name of Person or Facility____________________________________________________________
(Phone) ( ____ ) ____________
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
3. The following person or facility is authorized to receive my Protected Health Information
Name of Person or Facility:____________________________________________________________ (Phone) ( ____ ) ____________
4. My health information will be used or disclosed for the following purpose(s) (ex: Marketing Activities, Fundraising Activities,
Employment Determination, Continued Care, Legal, Claims etc.): _______________________________________________________
5. This Authorization applies to the following information*:
q The following records or types of health information (specify date(s) of service):________________________________________
q Discharge Summary
q X-ray Film (avail from Radiology Dept)
q Consultation Report
q X-ray Report
q Cardiopulmonary/EKG Report
q Multidisciplinary Notes
q Physical Therapy Notes
q Nursing Notes
q Physician Progress Notes
q Operative Report
q Billing Information (available
q Emergency Room Report
q Laboratory and Pathology Report
from Patient Financial Services)
q History and Physical
q Other (Please Specify)______________________________________________
Social Security #: ________________________ (Optional)
Name of Person or Facility____________________________________________________________ (Phone) ( ____ ) ____________
3. The following person or facility is authorized to receive my Protected Health Information
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
(eve) ( ____ ) ____________
2. The following person or facility is authorized to disclose my Protected Health Information
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
Physician:
Name of Person or Facility:__Family
__________________________________________________________
(Phone) ( ____ ) ____________
Medical Record Number (if known) __________________________
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
4. My health information will be used or disclosed for the following purpose(s) (ex: Marketing Activities, Fundraising Activities,
Employment Determination, Continued Care, Legal, Claims etc.): _______________________________________________________
6. Patient Only
q Paper
qElectronic
5. This Authorization applies to the following information*:
q The following records or types of health information (specify date(s) of service):________________________________________
q Discharge Summary
q X-ray Film (avail from Radiology Dept)
q Consultation Report
q X-ray Report
q Cardiopulmonary/EKG Report
q Multidisciplinary Notes
q Physical Therapy Notes
q Nursing Notes
q Physician Progress Notes
q Operative Report
q Billing Information (available
q Emergency Room Report
q Laboratory and Pathology Report
from Patient Financial Services)
q History and Physical
q Other (Please Specify)______________________________________________
* Information about the diagnosis and testing for HIV, AIDS, and ARC; Information about alcohol and drug treatment; and Information about mental
health services and social services (including communications made to a social worker or mental health professional) may be contained in these
documents and will be disclosed if it is part of the requested records. If you do not wish to have this information disclosed, please initial here:_______ .
* Information about the diagnosis and testing for HIV, AIDS, and ARC; Information about alcohol and drug treatment; and Information about mental
health services and social services (including communications made to a social worker or mental health professional) may be contained in these
documents and will be disclosed if it is part of the requested records. If you do not wish to have this information disclosed, please initial here:_______ .
7. This Authorization expires:__________________________________________ (if no expiration date or event is listed, this
authorization will expire 90 days after the date of request or at the completion of the request, whichever is earlier)
6. This Authorization expires:__________________________________________ (if no expiration date or event is listed, this
authorization will expire 90 days after the date of request or at the completion of the request, whichever is earlier)
q If this box is checked, I understand that the person or facility requesting my authorization will receive direct or indirect payment for the uses and
disclosures I have authorized.
__________________________________________________ Signature of Patient or Personal Representative
__________________________________________________
Relationship to the patient (if Personal Representative)
For Office Use Only: Identity and Authority Validated: __________ (initials)
Date Request Received ______________
Notice Of Federal And State Laws Regarding Further Disclosure To The Person Or Organization Receiving Information“This information may have
been disclosed to you from records whose confidentiality is protected by Federal and State Laws. Federal regulations (42 CFR, part 2) and State law (Public Act 258, Chapter
7, section 748) prohibit you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such
regulations. A general authorization for the release of medical or other information is NOT sufficient for this purpose.”
*AA1008*
Please see Pg. 2 for information on your rights and for mailing information
1
292348 / 09006 R 8/12 (M)D
q If this box is checked, I understand that the person or facility requesting my authorization will receive direct or indirect payment for the uses and
disclosures I have authorized.
__________________________________________________ Signature of Patient or Personal Representative
__________________________________________________
Relationship to the patient (if Personal Representative)
For Office Use Only: Identity and Authority Validated: __________ (initials)
Date Request Received ______________
Notice Of Federal And State Laws Regarding Further Disclosure To The Person Or Organization Receiving Information“This information may have
been disclosed to you from records whose confidentiality is protected by Federal and State Laws. Federal regulations (42 CFR, part 2) and State law (Public Act 258, Chapter
7, section 748) prohibit you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such
regulations. A general authorization for the release of medical or other information is NOT sufficient for this purpose.”
*AA1008*
Please see Pg. 2 for information on your rights and for mailing information
1
292348 / 09006 R 9/04 (M)D
YOUR RIGHTS:
YOUR RIGHTS:
I understand that if the person or entity that receives the information is not a health care provider or health plan covered
by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these
regulations. An exception for registered substance abuse and chemical dependency clients applies. See notice below.
I understand that if the person or entity that receives the information is not a health care provider or health plan covered
by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these
regulations. An exception for registered substance abuse and chemical dependency clients applies. See notice below.
I understand that I may revoke this limited Authorization in writing at any time at the address found below, except to the
extent that action has been taken in reliance on this Authorization. This Authorization is in effect until revoked by me or
until it expires under applicable laws. An exception for registered chemical dependency and substance abuse patients who
are involved in the Criminal Justice System when the consent is a condition of parole, probation or release from confinement
applies. In these cases this consent may not be revoked at any time unless there has been a formal and effective termination or
revocation of such release from confinement, probation or parole.
I understand that I may revoke this limited Authorization in writing at any time at the address found below, except to the
extent that action has been taken in reliance on this Authorization. This Authorization is in effect until revoked by me or
until it expires under applicable laws. An exception for registered chemical dependency and substance abuse patients who
are involved in the Criminal Justice System when the consent is a condition of parole, probation or release from confinement
applies. In these cases this consent may not be revoked at any time unless there has been a formal and effective termination or
revocation of such release from confinement, probation or parole.
This form should be mailed to:
qSaint Joseph Mercy Health System
Health Information Services Department
5301 East Huron River Drive
PO Box 995
Ann Arbor, MI, 48106-0995
This form should be mailed to:
qSaint Joseph Mercy Health System
Health Information Services Department
5301 East Huron River Drive
PO Box 995
Ann Arbor, MI, 48106-0995
I understand that I may refuse to sign this Authorization and that my refusal to sign will not affect the use or disclosure of
my protected health information for purposes of treatment, payment or health care operations. I may inspect or copy any
information used/disclosed under this Authorization.
qSt. Joseph Mercy Livingston Hospital
Health Information Services Department
620 Byron Road
Howell, MI 48843
I understand that I may refuse to sign this Authorization and that my refusal to sign will not affect the use or disclosure of
my protected health information for purposes of treatment, payment or health care operations. I may inspect or copy any
information used/disclosed under this Authorization.
q Other______________________________________________________________________________________________
q__________________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
REVOCATION OF THIS AUTHORIZATION
____________________________________________________________________________________________
____________________________________________________________________________________________
REVOCATION OF THIS AUTHORIZATION
I hereby revoke the authorization made on _____________.
I hereby revoke the authorization made on _____________.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
______________________________________________________
Signature of Patient or Representative
__________________________
Date/Time
__________________________________________________________________________________________________
__________________________________________________________________________________________________
______________________________________________________
Signature of Patient or Representative
__________________________________________________________
Relationship to the patient (if Personal Representative)
__________________________________________________________
Relationship to the patient (if Personal Representative)
This revocation should be mailed to:
Saint Joseph Mercy Health System
Health Information Services Department
5301 East Huron River Drive
PO Box 995
Ann Arbor, MI, 48106-0995
This revocation should be mailed to:
Saint Joseph Mercy Health System
Health Information Services Department
5301 East Huron River Drive
PO Box 995
Ann Arbor, MI, 48106-0995
2
2
__________________________
Date/Time
General Authorization for Use or
Disclosure of Health Information
General Authorization for Use or
Disclosure of Health Information
Completion of this document authorizes the disclosure and/or use of individually identifiable health information, consistent with applicable
State and Federal law. Failure to provide all information requested may invalidate this Authorization.
Date of Request: _______________
Medical Record Number (if known) __________________________
1. Protected health information may be used or disclosed regarding the following person:
Name: (Last)_____________________________________ (First)___________________(M.I.)________ Date Of Birth __________
Completion of this document authorizes the disclosure and/or use of individually identifiable health information, consistent with applicable
State and Federal law. Failure to provide all information requested may invalidate this Authorization.
Date of Request: _______________
1. Protected health information may be used or disclosed regarding the following person:
Name: (Last)_____________________________________ (First)___________________(M.I.)________ Date Of Birth __________
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
Telephone: (day) ( ____ ) ____________
(eve) ( ____ ) ____________
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
Social Security #: ________________________ (Optional)
Telephone: (day) ( ____ ) ____________
2. The following person or facility is authorized to disclose my Protected Health Information
Adult Partial Hospitalization Program
Name of Person or Facility____________________________________________________________
(Phone) ( ____ ) ____________
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
3. The following person or facility is authorized to receive my Protected Health Information
Name of Person or Facility:____________________________________________________________ (Phone) ( ____ ) ____________
4. My health information will be used or disclosed for the following purpose(s) (ex: Marketing Activities, Fundraising Activities,
Employment Determination, Continued Care, Legal, Claims etc.): _______________________________________________________
5. This Authorization applies to the following information*:
q The following records or types of health information (specify date(s) of service):________________________________________
q Discharge Summary
q X-ray Film (avail from Radiology Dept)
q Consultation Report
q X-ray Report
q Cardiopulmonary/EKG Report
q Multidisciplinary Notes
q Physical Therapy Notes
q Nursing Notes
q Physician Progress Notes
q Operative Report
q Billing Information (available
q Emergency Room Report
q Laboratory and Pathology Report
from Patient Financial Services)
q History and Physical
q Other (Please Specify)______________________________________________
Social Security #: ________________________ (Optional)
Name of Person or Facility____________________________________________________________ (Phone) ( ____ ) ____________
3. The following person or facility is authorized to receive my Protected Health Information
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
(eve) ( ____ ) ____________
2. The following person or facility is authorized to disclose my Protected Health Information
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
Name of Person or Facility:__Psychiatrist:
__________________________________________________________ (Phone) ( ____ ) ____________
Medical Record Number (if known) __________________________
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
4. My health information will be used or disclosed for the following purpose(s) (ex: Marketing Activities, Fundraising Activities,
Employment Determination, Continued Care, Legal, Claims etc.): _______________________________________________________
6. Patient Only
q Paper
qElectronic
5. This Authorization applies to the following information*:
q The following records or types of health information (specify date(s) of service):________________________________________
q Discharge Summary
q X-ray Film (avail from Radiology Dept)
q Consultation Report
q X-ray Report
q Cardiopulmonary/EKG Report
q Multidisciplinary Notes
q Physical Therapy Notes
q Nursing Notes
q Physician Progress Notes
q Operative Report
q Billing Information (available
q Emergency Room Report
q Laboratory and Pathology Report
from Patient Financial Services)
q History and Physical
q Other (Please Specify)______________________________________________
* Information about the diagnosis and testing for HIV, AIDS, and ARC; Information about alcohol and drug treatment; and Information about mental
health services and social services (including communications made to a social worker or mental health professional) may be contained in these
documents and will be disclosed if it is part of the requested records. If you do not wish to have this information disclosed, please initial here:_______ .
* Information about the diagnosis and testing for HIV, AIDS, and ARC; Information about alcohol and drug treatment; and Information about mental
health services and social services (including communications made to a social worker or mental health professional) may be contained in these
documents and will be disclosed if it is part of the requested records. If you do not wish to have this information disclosed, please initial here:_______ .
7. This Authorization expires:__________________________________________ (if no expiration date or event is listed, this
authorization will expire 90 days after the date of request or at the completion of the request, whichever is earlier)
6. This Authorization expires:__________________________________________ (if no expiration date or event is listed, this
authorization will expire 90 days after the date of request or at the completion of the request, whichever is earlier)
q If this box is checked, I understand that the person or facility requesting my authorization will receive direct or indirect payment for the uses and
disclosures I have authorized.
__________________________________________________ Signature of Patient or Personal Representative
__________________________________________________
Relationship to the patient (if Personal Representative)
For Office Use Only: Identity and Authority Validated: __________ (initials)
Date Request Received ______________
Notice Of Federal And State Laws Regarding Further Disclosure To The Person Or Organization Receiving Information“This information may have
been disclosed to you from records whose confidentiality is protected by Federal and State Laws. Federal regulations (42 CFR, part 2) and State law (Public Act 258, Chapter
7, section 748) prohibit you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such
regulations. A general authorization for the release of medical or other information is NOT sufficient for this purpose.”
*AA1008*
Please see Pg. 2 for information on your rights and for mailing information
1
292348 / 09006 R 8/12 (M)D
q If this box is checked, I understand that the person or facility requesting my authorization will receive direct or indirect payment for the uses and
disclosures I have authorized.
__________________________________________________ Signature of Patient or Personal Representative
__________________________________________________
Relationship to the patient (if Personal Representative)
For Office Use Only: Identity and Authority Validated: __________ (initials)
Date Request Received ______________
Notice Of Federal And State Laws Regarding Further Disclosure To The Person Or Organization Receiving Information“This information may have
been disclosed to you from records whose confidentiality is protected by Federal and State Laws. Federal regulations (42 CFR, part 2) and State law (Public Act 258, Chapter
7, section 748) prohibit you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such
regulations. A general authorization for the release of medical or other information is NOT sufficient for this purpose.”
*AA1008*
Please see Pg. 2 for information on your rights and for mailing information
1
292348 / 09006 R 9/04 (M)D
YOUR RIGHTS:
YOUR RIGHTS:
I understand that if the person or entity that receives the information is not a health care provider or health plan covered
by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these
regulations. An exception for registered substance abuse and chemical dependency clients applies. See notice below.
I understand that if the person or entity that receives the information is not a health care provider or health plan covered
by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these
regulations. An exception for registered substance abuse and chemical dependency clients applies. See notice below.
I understand that I may revoke this limited Authorization in writing at any time at the address found below, except to the
extent that action has been taken in reliance on this Authorization. This Authorization is in effect until revoked by me or
until it expires under applicable laws. An exception for registered chemical dependency and substance abuse patients who
are involved in the Criminal Justice System when the consent is a condition of parole, probation or release from confinement
applies. In these cases this consent may not be revoked at any time unless there has been a formal and effective termination or
revocation of such release from confinement, probation or parole.
I understand that I may revoke this limited Authorization in writing at any time at the address found below, except to the
extent that action has been taken in reliance on this Authorization. This Authorization is in effect until revoked by me or
until it expires under applicable laws. An exception for registered chemical dependency and substance abuse patients who
are involved in the Criminal Justice System when the consent is a condition of parole, probation or release from confinement
applies. In these cases this consent may not be revoked at any time unless there has been a formal and effective termination or
revocation of such release from confinement, probation or parole.
This form should be mailed to:
qSaint Joseph Mercy Health System
Health Information Services Department
5301 East Huron River Drive
PO Box 995
Ann Arbor, MI, 48106-0995
This form should be mailed to:
qSaint Joseph Mercy Health System
Health Information Services Department
5301 East Huron River Drive
PO Box 995
Ann Arbor, MI, 48106-0995
I understand that I may refuse to sign this Authorization and that my refusal to sign will not affect the use or disclosure of
my protected health information for purposes of treatment, payment or health care operations. I may inspect or copy any
information used/disclosed under this Authorization.
qSt. Joseph Mercy Livingston Hospital
Health Information Services Department
620 Byron Road
Howell, MI 48843
I understand that I may refuse to sign this Authorization and that my refusal to sign will not affect the use or disclosure of
my protected health information for purposes of treatment, payment or health care operations. I may inspect or copy any
information used/disclosed under this Authorization.
q Other______________________________________________________________________________________________
q__________________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
REVOCATION OF THIS AUTHORIZATION
____________________________________________________________________________________________
____________________________________________________________________________________________
REVOCATION OF THIS AUTHORIZATION
I hereby revoke the authorization made on _____________.
I hereby revoke the authorization made on _____________.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
______________________________________________________
Signature of Patient or Representative
__________________________
Date/Time
__________________________________________________________________________________________________
__________________________________________________________________________________________________
______________________________________________________
Signature of Patient or Representative
__________________________________________________________
Relationship to the patient (if Personal Representative)
__________________________________________________________
Relationship to the patient (if Personal Representative)
This revocation should be mailed to:
Saint Joseph Mercy Health System
Health Information Services Department
5301 East Huron River Drive
PO Box 995
Ann Arbor, MI, 48106-0995
This revocation should be mailed to:
Saint Joseph Mercy Health System
Health Information Services Department
5301 East Huron River Drive
PO Box 995
Ann Arbor, MI, 48106-0995
2
2
__________________________
Date/Time
General Authorization for Use or
Disclosure of Health Information
General Authorization for Use or
Disclosure of Health Information
Completion of this document authorizes the disclosure and/or use of individually identifiable health information, consistent with applicable
State and Federal law. Failure to provide all information requested may invalidate this Authorization.
Date of Request: _______________
Medical Record Number (if known) __________________________
1. Protected health information may be used or disclosed regarding the following person:
Name: (Last)_____________________________________ (First)___________________(M.I.)________ Date Of Birth __________
Completion of this document authorizes the disclosure and/or use of individually identifiable health information, consistent with applicable
State and Federal law. Failure to provide all information requested may invalidate this Authorization.
Date of Request: _______________
1. Protected health information may be used or disclosed regarding the following person:
Name: (Last)_____________________________________ (First)___________________(M.I.)________ Date Of Birth __________
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
Telephone: (day) ( ____ ) ____________
(eve) ( ____ ) ____________
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
Social Security #: ________________________ (Optional)
Telephone: (day) ( ____ ) ____________
2. The following person or facility is authorized to disclose my Protected Health Information
Adult Partial Hospitalization Program
Name of Person or Facility____________________________________________________________
(Phone) ( ____ ) ____________
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
3. The following person or facility is authorized to receive my Protected Health Information
Name of Person or Facility:____________________________________________________________ (Phone) ( ____ ) ____________
4. My health information will be used or disclosed for the following purpose(s) (ex: Marketing Activities, Fundraising Activities,
Employment Determination, Continued Care, Legal, Claims etc.): _______________________________________________________
5. This Authorization applies to the following information*:
q The following records or types of health information (specify date(s) of service):________________________________________
q Discharge Summary
q X-ray Film (avail from Radiology Dept)
q Consultation Report
q X-ray Report
q Cardiopulmonary/EKG Report
q Multidisciplinary Notes
q Physical Therapy Notes
q Nursing Notes
q Physician Progress Notes
q Operative Report
q Billing Information (available
q Emergency Room Report
q Laboratory and Pathology Report
from Patient Financial Services)
q History and Physical
q Other (Please Specify)______________________________________________
Social Security #: ________________________ (Optional)
Name of Person or Facility____________________________________________________________ (Phone) ( ____ ) ____________
3. The following person or facility is authorized to receive my Protected Health Information
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
(eve) ( ____ ) ____________
2. The following person or facility is authorized to disclose my Protected Health Information
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
Therapist:
Name of Person or Facility:__Primary
__________________________________________________________
(Phone) ( ____ ) ____________
Medical Record Number (if known) __________________________
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
4. My health information will be used or disclosed for the following purpose(s) (ex: Marketing Activities, Fundraising Activities,
Employment Determination, Continued Care, Legal, Claims etc.): _______________________________________________________
6. Patient Only
q Paper
qElectronic
5. This Authorization applies to the following information*:
q The following records or types of health information (specify date(s) of service):________________________________________
q Discharge Summary
q X-ray Film (avail from Radiology Dept)
q Consultation Report
q X-ray Report
q Cardiopulmonary/EKG Report
q Multidisciplinary Notes
q Physical Therapy Notes
q Nursing Notes
q Physician Progress Notes
q Operative Report
q Billing Information (available
q Emergency Room Report
q Laboratory and Pathology Report
from Patient Financial Services)
q History and Physical
q Other (Please Specify)______________________________________________
* Information about the diagnosis and testing for HIV, AIDS, and ARC; Information about alcohol and drug treatment; and Information about mental
health services and social services (including communications made to a social worker or mental health professional) may be contained in these
documents and will be disclosed if it is part of the requested records. If you do not wish to have this information disclosed, please initial here:_______ .
* Information about the diagnosis and testing for HIV, AIDS, and ARC; Information about alcohol and drug treatment; and Information about mental
health services and social services (including communications made to a social worker or mental health professional) may be contained in these
documents and will be disclosed if it is part of the requested records. If you do not wish to have this information disclosed, please initial here:_______ .
7. This Authorization expires:__________________________________________ (if no expiration date or event is listed, this
authorization will expire 90 days after the date of request or at the completion of the request, whichever is earlier)
6. This Authorization expires:__________________________________________ (if no expiration date or event is listed, this
authorization will expire 90 days after the date of request or at the completion of the request, whichever is earlier)
q If this box is checked, I understand that the person or facility requesting my authorization will receive direct or indirect payment for the uses and
disclosures I have authorized.
__________________________________________________ Signature of Patient or Personal Representative
__________________________________________________
Relationship to the patient (if Personal Representative)
For Office Use Only: Identity and Authority Validated: __________ (initials)
Date Request Received ______________
Notice Of Federal And State Laws Regarding Further Disclosure To The Person Or Organization Receiving Information“This information may have
been disclosed to you from records whose confidentiality is protected by Federal and State Laws. Federal regulations (42 CFR, part 2) and State law (Public Act 258, Chapter
7, section 748) prohibit you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such
regulations. A general authorization for the release of medical or other information is NOT sufficient for this purpose.”
*AA1008*
Please see Pg. 2 for information on your rights and for mailing information
1
292348 / 09006 R 8/12 (M)D
q If this box is checked, I understand that the person or facility requesting my authorization will receive direct or indirect payment for the uses and
disclosures I have authorized.
__________________________________________________ Signature of Patient or Personal Representative
__________________________________________________
Relationship to the patient (if Personal Representative)
For Office Use Only: Identity and Authority Validated: __________ (initials)
Date Request Received ______________
Notice Of Federal And State Laws Regarding Further Disclosure To The Person Or Organization Receiving Information“This information may have
been disclosed to you from records whose confidentiality is protected by Federal and State Laws. Federal regulations (42 CFR, part 2) and State law (Public Act 258, Chapter
7, section 748) prohibit you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such
regulations. A general authorization for the release of medical or other information is NOT sufficient for this purpose.”
*AA1008*
Please see Pg. 2 for information on your rights and for mailing information
1
292348 / 09006 R 9/04 (M)D
YOUR RIGHTS:
YOUR RIGHTS:
I understand that if the person or entity that receives the information is not a health care provider or health plan covered
by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these
regulations. An exception for registered substance abuse and chemical dependency clients applies. See notice below.
I understand that if the person or entity that receives the information is not a health care provider or health plan covered
by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these
regulations. An exception for registered substance abuse and chemical dependency clients applies. See notice below.
I understand that I may revoke this limited Authorization in writing at any time at the address found below, except to the
extent that action has been taken in reliance on this Authorization. This Authorization is in effect until revoked by me or
until it expires under applicable laws. An exception for registered chemical dependency and substance abuse patients who
are involved in the Criminal Justice System when the consent is a condition of parole, probation or release from confinement
applies. In these cases this consent may not be revoked at any time unless there has been a formal and effective termination or
revocation of such release from confinement, probation or parole.
I understand that I may revoke this limited Authorization in writing at any time at the address found below, except to the
extent that action has been taken in reliance on this Authorization. This Authorization is in effect until revoked by me or
until it expires under applicable laws. An exception for registered chemical dependency and substance abuse patients who
are involved in the Criminal Justice System when the consent is a condition of parole, probation or release from confinement
applies. In these cases this consent may not be revoked at any time unless there has been a formal and effective termination or
revocation of such release from confinement, probation or parole.
This form should be mailed to:
qSaint Joseph Mercy Health System
Health Information Services Department
5301 East Huron River Drive
PO Box 995
Ann Arbor, MI, 48106-0995
This form should be mailed to:
qSaint Joseph Mercy Health System
Health Information Services Department
5301 East Huron River Drive
PO Box 995
Ann Arbor, MI, 48106-0995
I understand that I may refuse to sign this Authorization and that my refusal to sign will not affect the use or disclosure of
my protected health information for purposes of treatment, payment or health care operations. I may inspect or copy any
information used/disclosed under this Authorization.
qSt. Joseph Mercy Livingston Hospital
Health Information Services Department
620 Byron Road
Howell, MI 48843
I understand that I may refuse to sign this Authorization and that my refusal to sign will not affect the use or disclosure of
my protected health information for purposes of treatment, payment or health care operations. I may inspect or copy any
information used/disclosed under this Authorization.
q Other______________________________________________________________________________________________
q__________________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
REVOCATION OF THIS AUTHORIZATION
____________________________________________________________________________________________
____________________________________________________________________________________________
REVOCATION OF THIS AUTHORIZATION
I hereby revoke the authorization made on _____________.
I hereby revoke the authorization made on _____________.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
______________________________________________________
Signature of Patient or Representative
__________________________
Date/Time
__________________________________________________________________________________________________
__________________________________________________________________________________________________
______________________________________________________
Signature of Patient or Representative
__________________________________________________________
Relationship to the patient (if Personal Representative)
__________________________________________________________
Relationship to the patient (if Personal Representative)
This revocation should be mailed to:
Saint Joseph Mercy Health System
Health Information Services Department
5301 East Huron River Drive
PO Box 995
Ann Arbor, MI, 48106-0995
This revocation should be mailed to:
Saint Joseph Mercy Health System
Health Information Services Department
5301 East Huron River Drive
PO Box 995
Ann Arbor, MI, 48106-0995
2
2
__________________________
Date/Time
General Authorization for Use or
Disclosure of Health Information
General Authorization for Use or
Disclosure of Health Information
Completion of this document authorizes the disclosure and/or use of individually identifiable health information, consistent with applicable
State and Federal law. Failure to provide all information requested may invalidate this Authorization.
Date of Request: _______________
Medical Record Number (if known) __________________________
1. Protected health information may be used or disclosed regarding the following person:
Name: (Last)_____________________________________ (First)___________________(M.I.)________ Date Of Birth __________
Completion of this document authorizes the disclosure and/or use of individually identifiable health information, consistent with applicable
State and Federal law. Failure to provide all information requested may invalidate this Authorization.
Date of Request: _______________
1. Protected health information may be used or disclosed regarding the following person:
Name: (Last)_____________________________________ (First)___________________(M.I.)________ Date Of Birth __________
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
Telephone: (day) ( ____ ) ____________
(eve) ( ____ ) ____________
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
Social Security #: ________________________ (Optional)
Telephone: (day) ( ____ ) ____________
2. The following person or facility is authorized to disclose my Protected Health Information
Family Members:
Name of Person or Facility____________________________________________________________
(Phone) ( ____ ) ____________
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
3. The following person or facility is authorized to receive my Protected Health Information
Name of Person or Facility:____________________________________________________________ (Phone) ( ____ ) ____________
4. My health information will be used or disclosed for the following purpose(s) (ex: Marketing Activities, Fundraising Activities,
Employment Determination, Continued Care, Legal, Claims etc.): _______________________________________________________
5. This Authorization applies to the following information*:
q The following records or types of health information (specify date(s) of service):________________________________________
q Discharge Summary
q X-ray Film (avail from Radiology Dept)
q Consultation Report
q X-ray Report
q Cardiopulmonary/EKG Report
q Multidisciplinary Notes
q Physical Therapy Notes
q Nursing Notes
q Physician Progress Notes
q Operative Report
q Billing Information (available
q Emergency Room Report
q Laboratory and Pathology Report
from Patient Financial Services)
q History and Physical
q Other (Please Specify)______________________________________________
Social Security #: ________________________ (Optional)
Name of Person or Facility____________________________________________________________ (Phone) ( ____ ) ____________
3. The following person or facility is authorized to receive my Protected Health Information
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
(eve) ( ____ ) ____________
2. The following person or facility is authorized to disclose my Protected Health Information
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
Partial Hospitalization Program
Name of Person or Facility:__Adult
__________________________________________________________
(Phone) ( ____ ) ____________
Medical Record Number (if known) __________________________
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
4. My health information will be used or disclosed for the following purpose(s) (ex: Marketing Activities, Fundraising Activities,
Employment Determination, Continued Care, Legal, Claims etc.): _______________________________________________________
6. Patient Only
q Paper
qElectronic
5. This Authorization applies to the following information*:
q The following records or types of health information (specify date(s) of service):________________________________________
q Discharge Summary
q X-ray Film (avail from Radiology Dept)
q Consultation Report
q X-ray Report
q Cardiopulmonary/EKG Report
q Multidisciplinary Notes
q Physical Therapy Notes
q Nursing Notes
q Physician Progress Notes
q Operative Report
q Billing Information (available
q Emergency Room Report
q Laboratory and Pathology Report
from Patient Financial Services)
q History and Physical
q Other (Please Specify)______________________________________________
* Information about the diagnosis and testing for HIV, AIDS, and ARC; Information about alcohol and drug treatment; and Information about mental
health services and social services (including communications made to a social worker or mental health professional) may be contained in these
documents and will be disclosed if it is part of the requested records. If you do not wish to have this information disclosed, please initial here:_______ .
* Information about the diagnosis and testing for HIV, AIDS, and ARC; Information about alcohol and drug treatment; and Information about mental
health services and social services (including communications made to a social worker or mental health professional) may be contained in these
documents and will be disclosed if it is part of the requested records. If you do not wish to have this information disclosed, please initial here:_______ .
7. This Authorization expires:__________________________________________ (if no expiration date or event is listed, this
authorization will expire 90 days after the date of request or at the completion of the request, whichever is earlier)
6. This Authorization expires:__________________________________________ (if no expiration date or event is listed, this
authorization will expire 90 days after the date of request or at the completion of the request, whichever is earlier)
q If this box is checked, I understand that the person or facility requesting my authorization will receive direct or indirect payment for the uses and
disclosures I have authorized.
__________________________________________________ Signature of Patient or Personal Representative
__________________________________________________
Relationship to the patient (if Personal Representative)
For Office Use Only: Identity and Authority Validated: __________ (initials)
Date Request Received ______________
Notice Of Federal And State Laws Regarding Further Disclosure To The Person Or Organization Receiving Information“This information may have
been disclosed to you from records whose confidentiality is protected by Federal and State Laws. Federal regulations (42 CFR, part 2) and State law (Public Act 258, Chapter
7, section 748) prohibit you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such
regulations. A general authorization for the release of medical or other information is NOT sufficient for this purpose.”
*AA1008*
Please see Pg. 2 for information on your rights and for mailing information
1
292348 / 09006 R 8/12 (M)D
q If this box is checked, I understand that the person or facility requesting my authorization will receive direct or indirect payment for the uses and
disclosures I have authorized.
__________________________________________________ Signature of Patient or Personal Representative
__________________________________________________
Relationship to the patient (if Personal Representative)
For Office Use Only: Identity and Authority Validated: __________ (initials)
Date Request Received ______________
Notice Of Federal And State Laws Regarding Further Disclosure To The Person Or Organization Receiving Information“This information may have
been disclosed to you from records whose confidentiality is protected by Federal and State Laws. Federal regulations (42 CFR, part 2) and State law (Public Act 258, Chapter
7, section 748) prohibit you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such
regulations. A general authorization for the release of medical or other information is NOT sufficient for this purpose.”
*AA1008*
Please see Pg. 2 for information on your rights and for mailing information
1
292348 / 09006 R 9/04 (M)D
YOUR RIGHTS:
YOUR RIGHTS:
I understand that if the person or entity that receives the information is not a health care provider or health plan covered
by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these
regulations. An exception for registered substance abuse and chemical dependency clients applies. See notice below.
I understand that if the person or entity that receives the information is not a health care provider or health plan covered
by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these
regulations. An exception for registered substance abuse and chemical dependency clients applies. See notice below.
I understand that I may revoke this limited Authorization in writing at any time at the address found below, except to the
extent that action has been taken in reliance on this Authorization. This Authorization is in effect until revoked by me or
until it expires under applicable laws. An exception for registered chemical dependency and substance abuse patients who
are involved in the Criminal Justice System when the consent is a condition of parole, probation or release from confinement
applies. In these cases this consent may not be revoked at any time unless there has been a formal and effective termination or
revocation of such release from confinement, probation or parole.
I understand that I may revoke this limited Authorization in writing at any time at the address found below, except to the
extent that action has been taken in reliance on this Authorization. This Authorization is in effect until revoked by me or
until it expires under applicable laws. An exception for registered chemical dependency and substance abuse patients who
are involved in the Criminal Justice System when the consent is a condition of parole, probation or release from confinement
applies. In these cases this consent may not be revoked at any time unless there has been a formal and effective termination or
revocation of such release from confinement, probation or parole.
This form should be mailed to:
qSaint Joseph Mercy Health System
Health Information Services Department
5301 East Huron River Drive
PO Box 995
Ann Arbor, MI, 48106-0995
This form should be mailed to:
qSaint Joseph Mercy Health System
Health Information Services Department
5301 East Huron River Drive
PO Box 995
Ann Arbor, MI, 48106-0995
I understand that I may refuse to sign this Authorization and that my refusal to sign will not affect the use or disclosure of
my protected health information for purposes of treatment, payment or health care operations. I may inspect or copy any
information used/disclosed under this Authorization.
qSt. Joseph Mercy Livingston Hospital
Health Information Services Department
620 Byron Road
Howell, MI 48843
I understand that I may refuse to sign this Authorization and that my refusal to sign will not affect the use or disclosure of
my protected health information for purposes of treatment, payment or health care operations. I may inspect or copy any
information used/disclosed under this Authorization.
q Other______________________________________________________________________________________________
q__________________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
REVOCATION OF THIS AUTHORIZATION
____________________________________________________________________________________________
____________________________________________________________________________________________
REVOCATION OF THIS AUTHORIZATION
I hereby revoke the authorization made on _____________.
I hereby revoke the authorization made on _____________.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
______________________________________________________
Signature of Patient or Representative
__________________________
Date/Time
__________________________________________________________________________________________________
__________________________________________________________________________________________________
______________________________________________________
Signature of Patient or Representative
__________________________________________________________
Relationship to the patient (if Personal Representative)
__________________________________________________________
Relationship to the patient (if Personal Representative)
This revocation should be mailed to:
Saint Joseph Mercy Health System
Health Information Services Department
5301 East Huron River Drive
PO Box 995
Ann Arbor, MI, 48106-0995
This revocation should be mailed to:
Saint Joseph Mercy Health System
Health Information Services Department
5301 East Huron River Drive
PO Box 995
Ann Arbor, MI, 48106-0995
2
2
__________________________
Date/Time
General Authorization for Use or
Disclosure of Health Information
General Authorization for Use or
Disclosure of Health Information
Completion of this document authorizes the disclosure and/or use of individually identifiable health information, consistent with applicable
State and Federal law. Failure to provide all information requested may invalidate this Authorization.
Date of Request: _______________
Medical Record Number (if known) __________________________
1. Protected health information may be used or disclosed regarding the following person:
Name: (Last)_____________________________________ (First)___________________(M.I.)________ Date Of Birth __________
Completion of this document authorizes the disclosure and/or use of individually identifiable health information, consistent with applicable
State and Federal law. Failure to provide all information requested may invalidate this Authorization.
Date of Request: _______________
1. Protected health information may be used or disclosed regarding the following person:
Name: (Last)_____________________________________ (First)___________________(M.I.)________ Date Of Birth __________
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
Telephone: (day) ( ____ ) ____________
(eve) ( ____ ) ____________
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
Social Security #: ________________________ (Optional)
Telephone: (day) ( ____ ) ____________
2. The following person or facility is authorized to disclose my Protected Health Information
Family Physician:
Name of Person or Facility____________________________________________________________
(Phone) ( ____ ) ____________
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
3. The following person or facility is authorized to receive my Protected Health Information
Name of Person or Facility:____________________________________________________________ (Phone) ( ____ ) ____________
4. My health information will be used or disclosed for the following purpose(s) (ex: Marketing Activities, Fundraising Activities,
Employment Determination, Continued Care, Legal, Claims etc.): _______________________________________________________
5. This Authorization applies to the following information*:
q The following records or types of health information (specify date(s) of service):________________________________________
q Discharge Summary
q X-ray Film (avail from Radiology Dept)
q Consultation Report
q X-ray Report
q Cardiopulmonary/EKG Report
q Multidisciplinary Notes
q Physical Therapy Notes
q Nursing Notes
q Physician Progress Notes
q Operative Report
q Billing Information (available
q Emergency Room Report
q Laboratory and Pathology Report
from Patient Financial Services)
q History and Physical
q Other (Please Specify)______________________________________________
Social Security #: ________________________ (Optional)
Name of Person or Facility____________________________________________________________ (Phone) ( ____ ) ____________
3. The following person or facility is authorized to receive my Protected Health Information
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
(eve) ( ____ ) ____________
2. The following person or facility is authorized to disclose my Protected Health Information
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
Partial Hospitalization Program
Name of Person or Facility:__Adult
__________________________________________________________
(Phone) ( ____ ) ____________
Medical Record Number (if known) __________________________
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
4. My health information will be used or disclosed for the following purpose(s) (ex: Marketing Activities, Fundraising Activities,
Employment Determination, Continued Care, Legal, Claims etc.): _______________________________________________________
6. Patient Only
q Paper
qElectronic
5. This Authorization applies to the following information*:
q The following records or types of health information (specify date(s) of service):________________________________________
q Discharge Summary
q X-ray Film (avail from Radiology Dept)
q Consultation Report
q X-ray Report
q Cardiopulmonary/EKG Report
q Multidisciplinary Notes
q Physical Therapy Notes
q Nursing Notes
q Physician Progress Notes
q Operative Report
q Billing Information (available
q Emergency Room Report
q Laboratory and Pathology Report
from Patient Financial Services)
q History and Physical
q Other (Please Specify)______________________________________________
* Information about the diagnosis and testing for HIV, AIDS, and ARC; Information about alcohol and drug treatment; and Information about mental
health services and social services (including communications made to a social worker or mental health professional) may be contained in these
documents and will be disclosed if it is part of the requested records. If you do not wish to have this information disclosed, please initial here:_______ .
* Information about the diagnosis and testing for HIV, AIDS, and ARC; Information about alcohol and drug treatment; and Information about mental
health services and social services (including communications made to a social worker or mental health professional) may be contained in these
documents and will be disclosed if it is part of the requested records. If you do not wish to have this information disclosed, please initial here:_______ .
7. This Authorization expires:__________________________________________ (if no expiration date or event is listed, this
authorization will expire 90 days after the date of request or at the completion of the request, whichever is earlier)
6. This Authorization expires:__________________________________________ (if no expiration date or event is listed, this
authorization will expire 90 days after the date of request or at the completion of the request, whichever is earlier)
q If this box is checked, I understand that the person or facility requesting my authorization will receive direct or indirect payment for the uses and
disclosures I have authorized.
__________________________________________________ Signature of Patient or Personal Representative
__________________________________________________
Relationship to the patient (if Personal Representative)
For Office Use Only: Identity and Authority Validated: __________ (initials)
Date Request Received ______________
Notice Of Federal And State Laws Regarding Further Disclosure To The Person Or Organization Receiving Information“This information may have
been disclosed to you from records whose confidentiality is protected by Federal and State Laws. Federal regulations (42 CFR, part 2) and State law (Public Act 258, Chapter
7, section 748) prohibit you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such
regulations. A general authorization for the release of medical or other information is NOT sufficient for this purpose.”
*AA1008*
Please see Pg. 2 for information on your rights and for mailing information
1
292348 / 09006 R 8/12 (M)D
q If this box is checked, I understand that the person or facility requesting my authorization will receive direct or indirect payment for the uses and
disclosures I have authorized.
__________________________________________________ Signature of Patient or Personal Representative
__________________________________________________
Relationship to the patient (if Personal Representative)
For Office Use Only: Identity and Authority Validated: __________ (initials)
Date Request Received ______________
Notice Of Federal And State Laws Regarding Further Disclosure To The Person Or Organization Receiving Information“This information may have
been disclosed to you from records whose confidentiality is protected by Federal and State Laws. Federal regulations (42 CFR, part 2) and State law (Public Act 258, Chapter
7, section 748) prohibit you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such
regulations. A general authorization for the release of medical or other information is NOT sufficient for this purpose.”
*AA1008*
Please see Pg. 2 for information on your rights and for mailing information
1
292348 / 09006 R 9/04 (M)D
YOUR RIGHTS:
YOUR RIGHTS:
I understand that if the person or entity that receives the information is not a health care provider or health plan covered
by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these
regulations. An exception for registered substance abuse and chemical dependency clients applies. See notice below.
I understand that if the person or entity that receives the information is not a health care provider or health plan covered
by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these
regulations. An exception for registered substance abuse and chemical dependency clients applies. See notice below.
I understand that I may revoke this limited Authorization in writing at any time at the address found below, except to the
extent that action has been taken in reliance on this Authorization. This Authorization is in effect until revoked by me or
until it expires under applicable laws. An exception for registered chemical dependency and substance abuse patients who
are involved in the Criminal Justice System when the consent is a condition of parole, probation or release from confinement
applies. In these cases this consent may not be revoked at any time unless there has been a formal and effective termination or
revocation of such release from confinement, probation or parole.
I understand that I may revoke this limited Authorization in writing at any time at the address found below, except to the
extent that action has been taken in reliance on this Authorization. This Authorization is in effect until revoked by me or
until it expires under applicable laws. An exception for registered chemical dependency and substance abuse patients who
are involved in the Criminal Justice System when the consent is a condition of parole, probation or release from confinement
applies. In these cases this consent may not be revoked at any time unless there has been a formal and effective termination or
revocation of such release from confinement, probation or parole.
This form should be mailed to:
qSaint Joseph Mercy Health System
Health Information Services Department
5301 East Huron River Drive
PO Box 995
Ann Arbor, MI, 48106-0995
This form should be mailed to:
qSaint Joseph Mercy Health System
Health Information Services Department
5301 East Huron River Drive
PO Box 995
Ann Arbor, MI, 48106-0995
I understand that I may refuse to sign this Authorization and that my refusal to sign will not affect the use or disclosure of
my protected health information for purposes of treatment, payment or health care operations. I may inspect or copy any
information used/disclosed under this Authorization.
qSt. Joseph Mercy Livingston Hospital
Health Information Services Department
620 Byron Road
Howell, MI 48843
I understand that I may refuse to sign this Authorization and that my refusal to sign will not affect the use or disclosure of
my protected health information for purposes of treatment, payment or health care operations. I may inspect or copy any
information used/disclosed under this Authorization.
q Other______________________________________________________________________________________________
q__________________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
REVOCATION OF THIS AUTHORIZATION
____________________________________________________________________________________________
____________________________________________________________________________________________
REVOCATION OF THIS AUTHORIZATION
I hereby revoke the authorization made on _____________.
I hereby revoke the authorization made on _____________.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
______________________________________________________
Signature of Patient or Representative
__________________________
Date/Time
__________________________________________________________________________________________________
__________________________________________________________________________________________________
______________________________________________________
Signature of Patient or Representative
__________________________________________________________
Relationship to the patient (if Personal Representative)
__________________________________________________________
Relationship to the patient (if Personal Representative)
This revocation should be mailed to:
Saint Joseph Mercy Health System
Health Information Services Department
5301 East Huron River Drive
PO Box 995
Ann Arbor, MI, 48106-0995
This revocation should be mailed to:
Saint Joseph Mercy Health System
Health Information Services Department
5301 East Huron River Drive
PO Box 995
Ann Arbor, MI, 48106-0995
2
2
__________________________
Date/Time
General Authorization for Use or
Disclosure of Health Information
General Authorization for Use or
Disclosure of Health Information
Completion of this document authorizes the disclosure and/or use of individually identifiable health information, consistent with applicable
State and Federal law. Failure to provide all information requested may invalidate this Authorization.
Date of Request: _______________
Medical Record Number (if known) __________________________
1. Protected health information may be used or disclosed regarding the following person:
Name: (Last)_____________________________________ (First)___________________(M.I.)________ Date Of Birth __________
Completion of this document authorizes the disclosure and/or use of individually identifiable health information, consistent with applicable
State and Federal law. Failure to provide all information requested may invalidate this Authorization.
Date of Request: _______________
1. Protected health information may be used or disclosed regarding the following person:
Name: (Last)_____________________________________ (First)___________________(M.I.)________ Date Of Birth __________
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
Telephone: (day) ( ____ ) ____________
(eve) ( ____ ) ____________
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
Social Security #: ________________________ (Optional)
Telephone: (day) ( ____ ) ____________
2. The following person or facility is authorized to disclose my Protected Health Information
Psychiatrist:
Name of Person or Facility____________________________________________________________
(Phone) ( ____ ) ____________
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
3. The following person or facility is authorized to receive my Protected Health Information
Name of Person or Facility:____________________________________________________________ (Phone) ( ____ ) ____________
4. My health information will be used or disclosed for the following purpose(s) (ex: Marketing Activities, Fundraising Activities,
Employment Determination, Continued Care, Legal, Claims etc.): _______________________________________________________
5. This Authorization applies to the following information*:
q The following records or types of health information (specify date(s) of service):________________________________________
q Discharge Summary
q X-ray Film (avail from Radiology Dept)
q Consultation Report
q X-ray Report
q Cardiopulmonary/EKG Report
q Multidisciplinary Notes
q Physical Therapy Notes
q Nursing Notes
q Physician Progress Notes
q Operative Report
q Billing Information (available
q Emergency Room Report
q Laboratory and Pathology Report
from Patient Financial Services)
q History and Physical
q Other (Please Specify)______________________________________________
Social Security #: ________________________ (Optional)
Name of Person or Facility____________________________________________________________ (Phone) ( ____ ) ____________
3. The following person or facility is authorized to receive my Protected Health Information
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
(eve) ( ____ ) ____________
2. The following person or facility is authorized to disclose my Protected Health Information
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
Partial Hospitalization Program
Name of Person or Facility:__Adult
__________________________________________________________
(Phone) ( ____ ) ____________
Medical Record Number (if known) __________________________
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
4. My health information will be used or disclosed for the following purpose(s) (ex: Marketing Activities, Fundraising Activities,
Employment Determination, Continued Care, Legal, Claims etc.): _______________________________________________________
6. Patient Only
q Paper
qElectronic
5. This Authorization applies to the following information*:
q The following records or types of health information (specify date(s) of service):________________________________________
q Discharge Summary
q X-ray Film (avail from Radiology Dept)
q Consultation Report
q X-ray Report
q Cardiopulmonary/EKG Report
q Multidisciplinary Notes
q Physical Therapy Notes
q Nursing Notes
q Physician Progress Notes
q Operative Report
q Billing Information (available
q Emergency Room Report
q Laboratory and Pathology Report
from Patient Financial Services)
q History and Physical
q Other (Please Specify)______________________________________________
* Information about the diagnosis and testing for HIV, AIDS, and ARC; Information about alcohol and drug treatment; and Information about mental
health services and social services (including communications made to a social worker or mental health professional) may be contained in these
documents and will be disclosed if it is part of the requested records. If you do not wish to have this information disclosed, please initial here:_______ .
* Information about the diagnosis and testing for HIV, AIDS, and ARC; Information about alcohol and drug treatment; and Information about mental
health services and social services (including communications made to a social worker or mental health professional) may be contained in these
documents and will be disclosed if it is part of the requested records. If you do not wish to have this information disclosed, please initial here:_______ .
7. This Authorization expires:__________________________________________ (if no expiration date or event is listed, this
authorization will expire 90 days after the date of request or at the completion of the request, whichever is earlier)
6. This Authorization expires:__________________________________________ (if no expiration date or event is listed, this
authorization will expire 90 days after the date of request or at the completion of the request, whichever is earlier)
q If this box is checked, I understand that the person or facility requesting my authorization will receive direct or indirect payment for the uses and
disclosures I have authorized.
__________________________________________________ Signature of Patient or Personal Representative
__________________________________________________
Relationship to the patient (if Personal Representative)
For Office Use Only: Identity and Authority Validated: __________ (initials)
Date Request Received ______________
Notice Of Federal And State Laws Regarding Further Disclosure To The Person Or Organization Receiving Information“This information may have
been disclosed to you from records whose confidentiality is protected by Federal and State Laws. Federal regulations (42 CFR, part 2) and State law (Public Act 258, Chapter
7, section 748) prohibit you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such
regulations. A general authorization for the release of medical or other information is NOT sufficient for this purpose.”
*AA1008*
Please see Pg. 2 for information on your rights and for mailing information
1
292348 / 09006 R 8/12 (M)D
q If this box is checked, I understand that the person or facility requesting my authorization will receive direct or indirect payment for the uses and
disclosures I have authorized.
__________________________________________________ Signature of Patient or Personal Representative
__________________________________________________
Relationship to the patient (if Personal Representative)
For Office Use Only: Identity and Authority Validated: __________ (initials)
Date Request Received ______________
Notice Of Federal And State Laws Regarding Further Disclosure To The Person Or Organization Receiving Information“This information may have
been disclosed to you from records whose confidentiality is protected by Federal and State Laws. Federal regulations (42 CFR, part 2) and State law (Public Act 258, Chapter
7, section 748) prohibit you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such
regulations. A general authorization for the release of medical or other information is NOT sufficient for this purpose.”
*AA1008*
Please see Pg. 2 for information on your rights and for mailing information
1
292348 / 09006 R 9/04 (M)D
YOUR RIGHTS:
YOUR RIGHTS:
I understand that if the person or entity that receives the information is not a health care provider or health plan covered
by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these
regulations. An exception for registered substance abuse and chemical dependency clients applies. See notice below.
I understand that if the person or entity that receives the information is not a health care provider or health plan covered
by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these
regulations. An exception for registered substance abuse and chemical dependency clients applies. See notice below.
I understand that I may revoke this limited Authorization in writing at any time at the address found below, except to the
extent that action has been taken in reliance on this Authorization. This Authorization is in effect until revoked by me or
until it expires under applicable laws. An exception for registered chemical dependency and substance abuse patients who
are involved in the Criminal Justice System when the consent is a condition of parole, probation or release from confinement
applies. In these cases this consent may not be revoked at any time unless there has been a formal and effective termination or
revocation of such release from confinement, probation or parole.
I understand that I may revoke this limited Authorization in writing at any time at the address found below, except to the
extent that action has been taken in reliance on this Authorization. This Authorization is in effect until revoked by me or
until it expires under applicable laws. An exception for registered chemical dependency and substance abuse patients who
are involved in the Criminal Justice System when the consent is a condition of parole, probation or release from confinement
applies. In these cases this consent may not be revoked at any time unless there has been a formal and effective termination or
revocation of such release from confinement, probation or parole.
This form should be mailed to:
qSaint Joseph Mercy Health System
Health Information Services Department
5301 East Huron River Drive
PO Box 995
Ann Arbor, MI, 48106-0995
This form should be mailed to:
qSaint Joseph Mercy Health System
Health Information Services Department
5301 East Huron River Drive
PO Box 995
Ann Arbor, MI, 48106-0995
I understand that I may refuse to sign this Authorization and that my refusal to sign will not affect the use or disclosure of
my protected health information for purposes of treatment, payment or health care operations. I may inspect or copy any
information used/disclosed under this Authorization.
qSt. Joseph Mercy Livingston Hospital
Health Information Services Department
620 Byron Road
Howell, MI 48843
I understand that I may refuse to sign this Authorization and that my refusal to sign will not affect the use or disclosure of
my protected health information for purposes of treatment, payment or health care operations. I may inspect or copy any
information used/disclosed under this Authorization.
q Other______________________________________________________________________________________________
q__________________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
REVOCATION OF THIS AUTHORIZATION
____________________________________________________________________________________________
____________________________________________________________________________________________
REVOCATION OF THIS AUTHORIZATION
I hereby revoke the authorization made on _____________.
I hereby revoke the authorization made on _____________.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
______________________________________________________
Signature of Patient or Representative
__________________________
Date/Time
__________________________________________________________________________________________________
__________________________________________________________________________________________________
______________________________________________________
Signature of Patient or Representative
__________________________________________________________
Relationship to the patient (if Personal Representative)
__________________________________________________________
Relationship to the patient (if Personal Representative)
This revocation should be mailed to:
Saint Joseph Mercy Health System
Health Information Services Department
5301 East Huron River Drive
PO Box 995
Ann Arbor, MI, 48106-0995
This revocation should be mailed to:
Saint Joseph Mercy Health System
Health Information Services Department
5301 East Huron River Drive
PO Box 995
Ann Arbor, MI, 48106-0995
2
2
__________________________
Date/Time
General Authorization for Use or
Disclosure of Health Information
General Authorization for Use or
Disclosure of Health Information
Completion of this document authorizes the disclosure and/or use of individually identifiable health information, consistent with applicable
State and Federal law. Failure to provide all information requested may invalidate this Authorization.
Date of Request: _______________
Medical Record Number (if known) __________________________
1. Protected health information may be used or disclosed regarding the following person:
Name: (Last)_____________________________________ (First)___________________(M.I.)________ Date Of Birth __________
Completion of this document authorizes the disclosure and/or use of individually identifiable health information, consistent with applicable
State and Federal law. Failure to provide all information requested may invalidate this Authorization.
Date of Request: _______________
1. Protected health information may be used or disclosed regarding the following person:
Name: (Last)_____________________________________ (First)___________________(M.I.)________ Date Of Birth __________
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
Telephone: (day) ( ____ ) ____________
(eve) ( ____ ) ____________
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
Social Security #: ________________________ (Optional)
Telephone: (day) ( ____ ) ____________
2. The following person or facility is authorized to disclose my Protected Health Information
Primary Therapist:
Name of Person or Facility____________________________________________________________
(Phone) ( ____ ) ____________
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
3. The following person or facility is authorized to receive my Protected Health Information
Name of Person or Facility:____________________________________________________________ (Phone) ( ____ ) ____________
4. My health information will be used or disclosed for the following purpose(s) (ex: Marketing Activities, Fundraising Activities,
Employment Determination, Continued Care, Legal, Claims etc.): _______________________________________________________
5. This Authorization applies to the following information*:
q The following records or types of health information (specify date(s) of service):________________________________________
q Discharge Summary
q X-ray Film (avail from Radiology Dept)
q Consultation Report
q X-ray Report
q Cardiopulmonary/EKG Report
q Multidisciplinary Notes
q Physical Therapy Notes
q Nursing Notes
q Physician Progress Notes
q Operative Report
q Billing Information (available
q Emergency Room Report
q Laboratory and Pathology Report
from Patient Financial Services)
q History and Physical
q Other (Please Specify)______________________________________________
Social Security #: ________________________ (Optional)
Name of Person or Facility____________________________________________________________ (Phone) ( ____ ) ____________
3. The following person or facility is authorized to receive my Protected Health Information
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
(eve) ( ____ ) ____________
2. The following person or facility is authorized to disclose my Protected Health Information
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
Partial Hospitalization Program
Name of Person or Facility:__Adult
__________________________________________________________
(Phone) ( ____ ) ____________
Medical Record Number (if known) __________________________
Address: (Street/box)__________________________________________ (City)___________________(State)_______(Zip)_________
4. My health information will be used or disclosed for the following purpose(s) (ex: Marketing Activities, Fundraising Activities,
Employment Determination, Continued Care, Legal, Claims etc.): _______________________________________________________
6. Patient Only
q Paper
qElectronic
5. This Authorization applies to the following information*:
q The following records or types of health information (specify date(s) of service):________________________________________
q Discharge Summary
q X-ray Film (avail from Radiology Dept)
q Consultation Report
q X-ray Report
q Cardiopulmonary/EKG Report
q Multidisciplinary Notes
q Physical Therapy Notes
q Nursing Notes
q Physician Progress Notes
q Operative Report
q Billing Information (available
q Emergency Room Report
q Laboratory and Pathology Report
from Patient Financial Services)
q History and Physical
q Other (Please Specify)______________________________________________
* Information about the diagnosis and testing for HIV, AIDS, and ARC; Information about alcohol and drug treatment; and Information about mental
health services and social services (including communications made to a social worker or mental health professional) may be contained in these
documents and will be disclosed if it is part of the requested records. If you do not wish to have this information disclosed, please initial here:_______ .
* Information about the diagnosis and testing for HIV, AIDS, and ARC; Information about alcohol and drug treatment; and Information about mental
health services and social services (including communications made to a social worker or mental health professional) may be contained in these
documents and will be disclosed if it is part of the requested records. If you do not wish to have this information disclosed, please initial here:_______ .
7. This Authorization expires:__________________________________________ (if no expiration date or event is listed, this
authorization will expire 90 days after the date of request or at the completion of the request, whichever is earlier)
6. This Authorization expires:__________________________________________ (if no expiration date or event is listed, this
authorization will expire 90 days after the date of request or at the completion of the request, whichever is earlier)
q If this box is checked, I understand that the person or facility requesting my authorization will receive direct or indirect payment for the uses and
disclosures I have authorized.
__________________________________________________ Signature of Patient or Personal Representative
__________________________________________________
Relationship to the patient (if Personal Representative)
For Office Use Only: Identity and Authority Validated: __________ (initials)
Date Request Received ______________
Notice Of Federal And State Laws Regarding Further Disclosure To The Person Or Organization Receiving Information“This information may have
been disclosed to you from records whose confidentiality is protected by Federal and State Laws. Federal regulations (42 CFR, part 2) and State law (Public Act 258, Chapter
7, section 748) prohibit you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such
regulations. A general authorization for the release of medical or other information is NOT sufficient for this purpose.”
*AA1008*
Please see Pg. 2 for information on your rights and for mailing information
1
292348 / 09006 R 8/12 (M)D
q If this box is checked, I understand that the person or facility requesting my authorization will receive direct or indirect payment for the uses and
disclosures I have authorized.
__________________________________________________ Signature of Patient or Personal Representative
__________________________________________________
Relationship to the patient (if Personal Representative)
For Office Use Only: Identity and Authority Validated: __________ (initials)
Date Request Received ______________
Notice Of Federal And State Laws Regarding Further Disclosure To The Person Or Organization Receiving Information“This information may have
been disclosed to you from records whose confidentiality is protected by Federal and State Laws. Federal regulations (42 CFR, part 2) and State law (Public Act 258, Chapter
7, section 748) prohibit you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such
regulations. A general authorization for the release of medical or other information is NOT sufficient for this purpose.”
*AA1008*
Please see Pg. 2 for information on your rights and for mailing information
1
292348 / 09006 R 9/04 (M)D
YOUR RIGHTS:
YOUR RIGHTS:
I understand that if the person or entity that receives the information is not a health care provider or health plan covered
by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these
regulations. An exception for registered substance abuse and chemical dependency clients applies. See notice below.
I understand that if the person or entity that receives the information is not a health care provider or health plan covered
by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these
regulations. An exception for registered substance abuse and chemical dependency clients applies. See notice below.
I understand that I may revoke this limited Authorization in writing at any time at the address found below, except to the
extent that action has been taken in reliance on this Authorization. This Authorization is in effect until revoked by me or
until it expires under applicable laws. An exception for registered chemical dependency and substance abuse patients who
are involved in the Criminal Justice System when the consent is a condition of parole, probation or release from confinement
applies. In these cases this consent may not be revoked at any time unless there has been a formal and effective termination or
revocation of such release from confinement, probation or parole.
I understand that I may revoke this limited Authorization in writing at any time at the address found below, except to the
extent that action has been taken in reliance on this Authorization. This Authorization is in effect until revoked by me or
until it expires under applicable laws. An exception for registered chemical dependency and substance abuse patients who
are involved in the Criminal Justice System when the consent is a condition of parole, probation or release from confinement
applies. In these cases this consent may not be revoked at any time unless there has been a formal and effective termination or
revocation of such release from confinement, probation or parole.
This form should be mailed to:
qSaint Joseph Mercy Health System
Health Information Services Department
5301 East Huron River Drive
PO Box 995
Ann Arbor, MI, 48106-0995
This form should be mailed to:
qSaint Joseph Mercy Health System
Health Information Services Department
5301 East Huron River Drive
PO Box 995
Ann Arbor, MI, 48106-0995
I understand that I may refuse to sign this Authorization and that my refusal to sign will not affect the use or disclosure of
my protected health information for purposes of treatment, payment or health care operations. I may inspect or copy any
information used/disclosed under this Authorization.
qSt. Joseph Mercy Livingston Hospital
Health Information Services Department
620 Byron Road
Howell, MI 48843
I understand that I may refuse to sign this Authorization and that my refusal to sign will not affect the use or disclosure of
my protected health information for purposes of treatment, payment or health care operations. I may inspect or copy any
information used/disclosed under this Authorization.
q Other______________________________________________________________________________________________
q__________________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
REVOCATION OF THIS AUTHORIZATION
____________________________________________________________________________________________
____________________________________________________________________________________________
REVOCATION OF THIS AUTHORIZATION
I hereby revoke the authorization made on _____________.
I hereby revoke the authorization made on _____________.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
______________________________________________________
Signature of Patient or Representative
__________________________
Date/Time
__________________________________________________________________________________________________
__________________________________________________________________________________________________
______________________________________________________
Signature of Patient or Representative
__________________________________________________________
Relationship to the patient (if Personal Representative)
__________________________________________________________
Relationship to the patient (if Personal Representative)
This revocation should be mailed to:
Saint Joseph Mercy Health System
Health Information Services Department
5301 East Huron River Drive
PO Box 995
Ann Arbor, MI, 48106-0995
This revocation should be mailed to:
Saint Joseph Mercy Health System
Health Information Services Department
5301 East Huron River Drive
PO Box 995
Ann Arbor, MI, 48106-0995
2
2
__________________________
Date/Time