Annette E. Barton, ACSW, BCD




In effect as of April 14, 2003


This notice describes the privacy policies and practices that I utilize. In addition, it will apply to any other therapist who provides "on call" coverage for me if I am unavailable, and to any therapist who provides supervision to me.


This notice applies to the information and records that I have about your health (mental and physical), the status of your mental and physical health, and the psychotherapy and other services that you receive at this office. HIPAA requires that I give you this notice. It will tell you about the ways in which I may use and disclose health information about you and describes your rights and my obligations regarding the use and disclosure of that information.


I may use and disclose health information about you for treatment, payment, and health care operations purposes with your consent. For example:

For Treatment I may use or disclose your health information to a physician or other healthcare provider providing treatment to you. An example of this would be when I consult with your psychiatrist, family physician, or another therapist to coordinate our care and treatment of you.

For Payment I may use and disclose health information about you so that the treatment and services that you receive at this office may be billed to, and payment may be collected from, you, an insurance company, or a third party.

For Healthcare Operations I may use and disclose health information about you in order to run the office and make sure that you and my other patients receive quality care. For example, I may share your information with a billing service or emergency answering service provided I have a contract with that service that safeguards the privacy of your information.

For Appointment Scheduling and Reminders I may contact you to schedule appointments or to remind you that you have an appointment. Please notify me if you do not wish to be contacted for appointment reminders and how you wish to be contacted to schedule appointments.

Uses and Disclosure of Information Requiring Your Authorization

An "authorization" is written permission above and beyond the general consent that permits only specific disclosures. In those instances when I am asked for information for purposes outside of treatment, payment or health care operations, I will obtain an authorization from you before releasing this information. I will also need to obtain an authorization before releasing your Psychotherapy Notes. "Psychotherapy Notes" are notes I have made about our conversation during a private, group, joint, or family counseling session, which I have kept separate from the rest of your medical record. These notes are given a greater degree of protection.

You may revoke all such authorizations (of Health Information or Psychotherapy Notes) at any time, provided each revocation is in writing.

You may not revoke an authorization to the extent that

(1) I have already relied on that authorization and released information

(2) If the authorization was obtained as a condition of obtaining insurance coverage, because the law provides the insurer the right to contest the claim under the policy.

Family and Friends - I may disclose health information about you to your family members, friends, or another person with your verbal or written authorization. If you provide verbal authorization, I will have you sign a written authorization the next time we meet. If you bring another person into a therapy session, I may assume you agree to my disclosure of your personal health information during that session.

Uses and Disclosures with Neither Consent nor Authorization

I may use or disclose your health information without your consent or authorization when it is required by law, when a court orders your records, and/or when there is a serious and imminent danger to yourself or others. Specific examples of this include:

Child Abuse - If I have reasonable cause to suspect child abuse or neglect, I must report this suspicion to the appropriate authorities as required by law.

Adult and Domestic Abuse - If I have reasonable cause to suspect you have been criminally abused, I must report this suspicion to the appropriate authorities as required by law.

Health Oversight Activities - If I receive a subpoena or other lawful request from the Department of Health or the Michigan Board of Examiners of Social Workers, I must disclose the relevant health information pursuant to that subpoena or lawful request.

Judicial and Administrative Proceedings – If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment or the records thereof, such information is privileged under state law, and I will not release information without your written authorization or a court order. The privilege does not apply when you are being evaluated by a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.

Serious Threat to Health or Safety – If you communicate to me a threat of physical violence against a reasonably identifiable third person and you have the apparent intent and ability to carry out that threat in the foreseeable future, I may disclose relevant health information and take the reasonable steps permitted by law to prevent the threatened harm from occurring. If I believe that there is an imminent risk that you will inflict serious physical harm on yourself, I may disclose information in order to protect you.

National Security and Intelligence – I may disclose to military authorities the health information of current or past Armed Forces personnel under certain circumstances. I may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities.


Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information. However, I am not required to agree to a restriction you request.

Right to Receive Confidential Communications by Alternative Means and at Alternative Locations You have the right to request and receive confidential communications of your health information by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing me. On your request, I will send your bills to another address.)

Right to Inspect and Copy – You have the right to inspect and/or obtain a copy of your health information in my mental health and billing records, that I use to make decisions about you for your care as long as the information is maintained in the record. Psychotherapy notes are specifically excluded and you do not have a right to inspect or copy them. You must submit a written request in order to inspect and/or have your records copied. If you request a copy of the information, I may charge a fee for the costs of copying, mailing, or other associated supplies. I may deny your access to your health information under certain circumstances. In some cases you may have this decision reviewed. If such a request is required by law, I will select a health care professional to review your request and my denial. The person conducting the review will not be the person who denied your request, and I will comply with the outcome of the review.

Right to Amend – If you believe that the health information I have about you is incorrect or incomplete, you may ask me to amend the information. You have the right to request an amendment as long as the information is kept by this office. To request an amendment, complete and submit a Medical Record Amendment/Correction Form. I may deny your request for an amendment if it is not in writing or does not include a reason to support the request.

In addition, I may deny your request if you ask me to amend information that

a) I did not create, unless the person or entity that created the information is no longer available to make the amendment

b) Is not part of the health information that I keep

c) You would not be permitted to inspect and copy

d) Is accurate and complete

Right to an Accounting of Disclosures – You generally have the right to receive an accounting of disclosures of your health information. This is a list of the disclosures I made of medical information about you for purposes other than treatment, payment and health care operations. To obtain this list, you must submit your request in writing. It must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. If you request this accounting more than once in a 12-month period, I may charge you for the costs of providing the list.

Right to a Paper Copy – You have the right to obtain a paper copy of the notice from me upon request, even if you have agreed to receive the notice electronically.

Right to Request Restrictions – You have the right to request additional restrictions on my use or disclosure of your health information. I am not required to agree to these additional restrictions, but if I do, I will abide by our agreement (except in an emergency). To request restrictions, you must complete and submit the Request For Restriction On Use /Disclosure of Medical Information Form.

Right to Request Confidential Communications – You have the right to request that I communicate with you about your health information in a certain way or at a certain location. For example, you may ask that I only contact you at work. To request confidential communications, you must complete and submit the Request For Confidential Communication Form. I will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.


I am required by law to maintain the privacy of your health information and to provide you with a notice of my legal duties and privacy practices with respect to this.

I reserve the right to change the privacy policies and practices described in this notice provided such changes are permitted by applicable law, and to make the revised or changed notice effective for health information I already have about you as well as any information I receive in the future.

If I revise my policies and procedures, I will post the current notice in my office and on my website – You are entitled to a copy of the notice currently in effect and if requested, may receive a copy at my office, by mail, or e-mail.


If you want more information about my privacy practices or have questions or concerns, please contact me. If you are concerned that I have violated your privacy rights, or you disagree with a decision I made about access to your records, you may contact me at 4660 Marsh Rd., P.O. Box 684, Okemos, MI  48805-0684.  (517) 347-7457.

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services or the Bureau of Health Services for the State of Michigan. I will provide you with these addresses at your request.

You will not be penalized for filing a complaint.