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We arecommitted to protecting medical information about you.  This Notice describes our privacy practices and that of all its employees and staff.  This Notice will tell you about the ways in which we may use and disclose medical information about you.  It also describes your rights and certain obligations we have regarding the use and disclosure of medical information.  We are required by law to: 

  • Give you this Notice of our legal duties and privacy practices with respect to medical information about you
  • Make sure that medical information that identifies you is kept private
  • Follow the terms of the Notice that is currently in effect



The following categories describe different ways we use and disclose health information that identifies you (“Health Information”).  For each category we will explain what we mean and try to give some examples.  Not every use or disclosure in a category will be listed.  However, all of the ways we are permitted to use and disclose information will fall within one of the categories. 

Treatment.  We may use and disclose Health Information for your treatment and to provide you with treatment-related health care services.  For example, we may disclose your Health Information to doctors, nurses, technicians, or other personnel, including people outside our office, who need the information to provide you with medical care.  

Payment.  We may use and disclose your Health Information so that we or others may bill and receive payment from you, an insurance company or a third party for the treatment and services you received.  For example, we may give your health plan information about services you received at our office so your health plan will pay us or reimburse you for the services.

Health Care Operations.  We may use and disclose Health Information for health care operations. These uses and disclosures are necessary to make sure that our patients receive quality care and to operate and manage our office.  For example, we may use Health Information to review our treatment and services and to evaluate the performance of our staff in caring for you.

Business Associates.  We may disclose Health Information to our contracted Business Associates that perform functions on our behalf.  For example, we may use another company to perform billing services. 

Appointment Reminders, Treatment Alternatives and Health-Related Benefits and Services.  As part of treatment activities or health care operations, we may use your Health Information to contact you as a reminder that you have an appointment with us. We also may use Health Information to tell you about treatment alternatives or health-related benefits and services that may be of interest to you.

Fundraising.  We may use and disclose limited Health Information to send you fundraising communications.  You have the right to "opt-out" of receiving these communications at any time.

Individuals Involved in Your Care or Payment for Your Care.  When appropriate, we may share your Health Information with a person who is involved in your medical care or payment of your care, such as your family or a close friend, so long as you have not objected and it is reasonable for us to believe that such disclosure is in your best interest. We also may notify your family about your location or general condition or disclose such information to an entity assisting in a disaster relief effort.

Research. Under certain circumstances, we may use and disclose Health Information for research activities. For example, a research project may involve comparing the health of patients who received one treatment to those who received another treatment for the same condition. Before we use or disclose Health Information for research, the project will go through a special approval process. 

Special Purposes When Permitted or Required by Law.  We may disclose Health Information about you for special purposes when permitted or required by law, including the following:

  • To avert a serious threat to health or safetyagainst you, the public or another person. 
  • For public health and administrative oversight activitiessuch as disease control, abuse or neglect reporting, health and vital statistics, audits, investigations, and licensure reviews.
  • For organ and tissue donation and transplant activities.
  • For workers’ compensation or similar programspurposes, such as for the payment of benefits for work-related injuries.
  • To coroners, medical examiners and funeral directorsto identify a deceased person, determine cause of death, or to carry out duties.
  • For judicial and administrative proceedings in response to a subpoena, court order, or administrative order, if certain requirements are met.
  • For law enforcement activities, if the disclosure is required by law, necessary to identify or locate a suspect or missing person, about criminal conduct on our premises, about inmates, about victims of crime under certain circumstances, and in certain emergency situations.
  • For U.S. military and veteran reporting obligationsregarding members and veterans of the armed forces of U.S. or foreign military.
  • For national security and intelligence activities, such as protective services for the President andother authorized persons.
  • When otherwise required by law.

State and Other Federal Laws.  We will comply with all applicable state and federal laws.  For example, under Michigan law, there are more limits on the disclosure of mental health information, substance abuse information, and HIV and AIDS information.  We will continue to abide by all applicable state and federal laws.

Other Uses of Medical Information Require an Authorization.  Other uses and disclosures of your Health Information that are not covered by this Notice will be made only with your written authorization, including for marketing purposes or sale of Health Information.  A written authorization is also required for most uses or disclosures of psychotherapy notes. 

If you provide us an authorization to use or disclose your Health Information, you may revoke that authorization, in writing, at any time.  If you revoke your authorization, we will no longer use or disclose your Health Information for the reasons covered by the written authorization.  You understand that we are unable to take back disclosures we have already made with your authorization, and that we are required to retain our records of the care that we provide to you.



 We may participate in a health information exchange organization (“HIE”) that permits computer-based transfer of Health Information directly between healthcare providers at different locations and institutions to facilitate your care and treatment. If you do not want your Health Information to be shared in this way, you can opt-out. 



You have many rights with regard to your Health Information.  If you wish to exercise any of these rights, we ask that you submit your request in writing.

Your Right to Access. You have the right to inspect and obtain a copy of your Health Information. This includes medical and billing records. You have the right to request this information in a particular electronic form or format.  You also have the right to request that we transmit a copy of your Health Information directly to you or another person designated by you.  We have up to 30 days to make your Health Information available to you and we may charge a reasonable fee for the costs of copying, mailing or other supplies associated with your request. We may not charge you a fee if you need the information for a claim for benefits under the Social Security Act or other state or federal need-based program. We may deny your request in certain limited circumstances. 

Your Right to Amend.  If you feel that your Health Information is incorrect or incomplete, you may ask us to amend the information.  You have the right to add a statement.  You must provide a reason that supports your request for an amendment.

Your Right to an Accounting of Disclosures.  You have the right to request a list of certain disclosures we made of your Health Information.  This is referred to as an "accounting of disclosures."  Your request must state a time period.  We may limit the time period to the prior 6 years.  The first list you request within a 12-month period is free.  For additional lists, we may charge you for the costs of providing the list.

Your Right to Request Restrictions.  You have the right to request a restriction or limitation on the how we use or disclose your Health Information for treatment, payment or operations. You also have the right to request a limit on the Health Information we disclose to someone involved in your care, like a family member or friend.  We have the right to deny your request, except if you have paid for the service out of pocket in full and you request that we not submit your information to your health plan. In this case, we must agree to the request.

Your Right to Request Confidential Communications.  You have the right to request that we communicate with you about medical matters in a certain way or at a certain location.  For example, you can ask that we only contact you at work or by mail.  We will not ask you the reason for your request. 

Right to Paper Copy of this Notice.  You have the right to a paper copy of this Notice.  You may ask us to give you a copy of this Notice at any time.

Right to File a Complaint.  If you believe your privacy rights have been violated, you may file a complaint with WSUPG. You may also file a complaint directly with the Secretary of the Department of Health and Human Services.  You will not be penalized in any way for filing a complaint.

Your Right to Receive Notice of a Breach. You have the right to be notified of a breach of your unsecured Health Information.  We will notify you by mail at your last known address.



We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current Notice at our offices and make copies available upon request.



For questions about this Privacy Notice, contact:

Privacy Officer
540 E. Canfield
Scott Hall, Room 1374
Detroit, MI 48201
Tel: 313-577-0558
FM.003 – Notice of Privacy Practices Form
Revised Effective Date: 09/23/13