Patient Privacy

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN 

GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

We are required by law to maintain the privacy of protected health information, to provide 
individuals with notice of our legal duties and privacy practices with respect to protected health 
information, and to notify affected individuals following a breach of unsecured protected health 
information. We must follow the privacy practices that are described in this Notice while it is in 
effect. This Notice takes effect February 16, 2026, and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, 
provided such changes are permitted by applicable law, and to make new Notice provisions effective 
for all protected health information that we maintain. When we make a significant change in our 
privacy practices, we will change this Notice and post the new Notice clearly and prominently at 
our practice location, and we will provide copies of the new Notice upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, 
or for additional copies of this Notice, please contact us using the information listed at the end 
of this Notice.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
We may use and disclose your health information for different purposes, including treatment, 
payment, and health care operations. For each of these categories, we have provided a description 
and an example. Some information, such as HIV-related information, genetic information, alcohol 
and/or substance abuse records, and mental health records may be entitled to special 
confidentiality protections under applicable state or federal law. We will abide by these special 
protections as they pertain to applicable cases involving these types of records.
Treatment. We may use and disclose your health information for your treatment. For example, we may 
disclose your health information to a specialist providing treatment to you.
Payment. We may use and disclose your health information to obtain reimbursement for the treatment 
and services you receive from us or another entity involved with your care. Payment activities 
include billing, collections, claims management, and determinations of eligibility and coverage to 
obtain payment from you, an insurance company, or another third party. For example, we may send 
claims to your dental health plan containing certain health information.

Healthcare Operations. We may use and disclose your health information in connection with our 
healthcare operations. For example, healthcare operations include quality assessment and 
improvement activities, conducting training programs, and licensing activities.
Individuals Involved in Your Care or Payment for Your Care. We may disclose your health information 
to your family or friends or any other individual identified by you when they participate in your 
care or in the payment for your care. Additionally, we may disclose information about you to a 
patient representative. If a person has the authority by law to make health care decisions for you, 
we will treat that patient representative the same way we would treat you with respect to your 
health information.

Disaster Relief. We may use or disclose your health information to assist in disaster relief 
efforts.

Required by Law. We may use or disclose your health information when we are required to do so by 
law.
Public Health Activities. We may disclose your health information for public health activities, 
including disclosures to:
•  Prevent or control disease, injury or disability;
•  Report child abuse or neglect;
•  Report reactions to medications or problems with products or devices;
•  Notify a person of a recall, repair, or replacement of products or devices;
•  Notify a person who may have been exposed to a disease or condition; or
•  Notify the appropriate government authority if we believe a patient has been the victim of 
abuse, neglect, or domestic violence.
National Security. We may disclose to military authorities the health information of Armed Forces 
personnel under certain circumstances. We may disclose to authorized federal officials health 
information required for lawful intelligence, counterintelligence, and other national security 
activities. We may disclose to correctional institution or law enforcement official having lawful 
custody the protected health information of an inmate or patient.
Secretary of HHS. We will disclose your health information to the Secretary of the U.S. Department 
of Health and Human Services when required to investigate or determine compliance with HIPAA.

Worker’s Compensation. We may disclose your PHI to the extent authorized by and to the extent 
necessary to comply with laws relating to worker’s compensation or other similar programs 
established by law.

Law Enforcement. We may disclose your PHI for law enforcement purposes as permitted by HIPAA, as 
required by law, or in response to a subpoena or court order.

Health Oversight Activities. We may disclose your PHI to an oversight agency for activities 
authorized by law. These oversight activities include audits, investigations, inspections, and 
credentialing, as necessary for licensure and for the government to monitor the health care system, 
government programs, and compliance with civil rights laws.
Judicial and Administrative Proceedings. If you are involved in a lawsuit or a dispute, we may 
disclose your PHI in response to a court or administrative order. We may also disclose health 
information about you in response to a subpoena, discovery request, or other lawful process 
instituted by someone else involved in the dispute, but only if efforts have been made, either by 
the requesting party or us, to tell you about the request or to obtain an order protecting the 
information requested.

Research. We may disclose your PHI to researchers when their research has been approved by an 
institutional review board or privacy board that has reviewed the research proposal and established 
protocols to ensure the privacy of your information.

Coroners, Medical Examiners, and Funeral Directors. We may release your PHI to a coroner or medical 
examiner. This may be necessary, for example, to identify a deceased person or determine the cause 
of death. We may also disclose PHI to funeral directors consistent with applicable law to enable 
them to perform their duties.

Fundraising. We may contact you to provide you with information about our sponsored activities, 
including fundraising programs, as permitted by applicable law. If you do not wish to receive such 
information from us, you may opt out of receiving the communications.
SUD Treatment Information. If we receive or maintain any information about you from a substance use 
disorder treatment program that is

covered by 42 CFR Part 2 (a “Part 2 Program”) through a general consent you provide to the Part 2 
Program to use and disclose the Part 2 Program record for purposes of treatment, payment or health 
care operations, we may use and disclose your Part 2 Program record for treatment, payment and 
health care operations purposes as described in this Notice. If we receive or maintain your Part 2 
Program record through specific consent you provide to us or another third party, we will use and 
disclose your Part 2 Program record only as expressly permitted by you in your consent as provided 
to us.
In no event will we use or disclose your Part 2 Program record, or testimony that describes the 
information contained in your Part 2 Program record, in any civil, criminal, administrative, or 
legislative proceedings by any Federal, State, or local authority, against you, unless authorized 
by your consent or the order of a court after it provides you notice of the court order.

Other Uses and Disclosures of PHI
Your authorization is required, with a few exceptions, for disclosure of psychotherapy notes, use 
or disclosure of PHI for marketing, and for the sale of PHI. We will also obtain your written 
authorization before using or disclosing your PHI for purposes other than those provided for in 
this Notice (or as otherwise permitted or required by law). You may revoke an authorization in 
writing at any time. Upon receipt of the written revocation, we will stop using or disclosing your 
PHI, except to the extent that we have already acted in reliance on the authorization.

Your Health Information Rights

Access. You have the right to look at or get copies of your health information, with limited 
exceptions. You must make the request in writing. You may obtain a form to request access by using 
the contact information listed at the end of this Notice. You may also request access by sending us 
a letter to the address at the end of this Notice. If you request information that we maintain on 
paper, we may provide photocopies. If you request information that we maintain electronically, you 
have the right to an electronic copy. We will use the form and format you request if readily 
producible. We will charge you a reasonable cost-based fee for the cost of supplies and labor of 
copying, and for postage if you want copies mailed to you. Contact us using the information listed 
at the end of this Notice for an explanation of our fee structure.
If you are denied a request for access, you have the right to have the denial reviewed in 
accordance with the requirements of applicable law.

Disclosure Accounting. With the exception of certain disclosures, you have the right to receive an 
accounting of disclosures of your health information in accordance with applicable laws and 
regulations. To request an accounting of disclosures of your health information, you must submit 
your request in writing to the Privacy Official. If you request this accounting more than once in a 
12-month period, we may charge you a reasonable, cost-based fee for responding to the additional 
requests.
Right to Request a Restriction. You have the right to request additional restrictions on our use or 
disclosure of your PHI by submitting a written request to the Privacy Official. Your written 
request must include (1) what information you want to limit, (2) whether you want to limit our use, 
disclosure or both, and (3) to whom you want the limits to apply. We are not required to agree to 
your request except in the case where the disclosure is to a health plan for purposes of carrying 
out payment or health care operations, and the information pertains solely to a health care item or 
service for which you, or a person on your behalf (other than the health plan), has paid our 
practice in full.
Alternative Communication. You have the right to request that we communicate with you about your 
health information by alternative means or at alternative locations. You must make your request in 
writing. Your request must specify the alternative means or location, and provide satisfactory 
explanation of how payments will be handled under the alternative means or location you request. We 
will accommodate all reasonable requests. However, if we are unable to contact you using the ways 
or locations you have requested, we may contact you using the information we have.

Amendment. You have the right to request that we amend your health information. Your request must 
be in writing, and it must explain why the information should be amended. We may deny your request 
under certain circumstances. If we agree to your request, we will amend your record(s) and notify 
you of such. If we deny your request for an amendment, we will provide you with a written 
explanation of why we denied it and explain your rights.

Right to Notification of a Breach. You will receive notifications of breaches of your unsecured 
protected health information as required by law.

Electronic Notice. You may receive a paper copy of this Notice upon request, even if you have 
agreed to receive this Notice electronically on our Web site or by electronic mail (e-mail).

Questions and Complaints
If you want more information about our privacy practices or have questions or concerns, please 
contact us.
If you are concerned that we may have violated your privacy rights, or if you disagree with a 
decision we made about access to your health information or in response to a request you made to 
amend or restrict the use or disclosure of your health information or to have us communicate with 
you by alternative means or at alternative locations, you may complain to us using the contact 
information listed at the end of this Notice. You also may submit a written complaint to the U.S. 
Department of Health and Human Services. We will provide you with the address to file your 
complaint with the U.S. Department of Health and Human Services upon request.
We support your right to the privacy of your health information. We will not retaliate in any way 
if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.
Our Privacy Official: Susan Kempf
Telephone: (586) 739-1210 Fax: (586) 739-9451

Address: 45100 Sterritt St, Ste 101, Utica, MI 48317
E-mail: [email protected]