Notice of Privacy Practices for Protected Health Information
I understand that my Protected Health Information (PHI) can be used for treatment, payment and health care options.
I understand that I have certain rights to restrict the use and disclosure of my PHI, to obtain a copy of the Notice of Privacy Practices
for Protected Health Information, to amend in order to correct incomplete or incorrect information in my records, to receive an
accounting of disclosures of my PHI, and to request that communication of my PHI be made by alternative or at an alternative location.
I understand that I can request additional information by contact the Practice Administrator at 586-779-9400.
I understand that I can file a complaint by contacting the Practice Administrator and that I may also file a complaint by contacting the
Secretary of Health and Human Services at 200 Independence Avenue SW, Room 615F, Washington, D.C. 20201 or e-mail at
I understand that I may be contacted by your office for appointment reminders, alternative treatment information, and with information
about other health-related benefits and services.
Unless I object, my PHI may be disclosed to assist in notifying a family member, and/or certain other individuals responsible for my
care about my location, general condition or my death. My PHI may also be disclosed to assist in disaster relief efforts.
I understand that my PHI may be disclosed as mandated and without my authorization in the following instances:
· Controlling Diseases· Research
· Child Abuse and Neglect
· Threat to Health and Safety
· Abuse, Neglect, or Domestic Violence
· Specialized Governmental Function
· Judicial/Administrative Procedures
· Workers Compensation
I understand that my PHI may be disclosed as mandated and without my authorization to the following agencies/individuals:
· Food and Drug Administration (FDA)
· Organ Procurement Organizations
· Oversight Agencies
· Correctional Institutions
· Law Enforcement
· Coroners, Medical Examiners, Funeral Directors
I understand that other uses of my PHI will be made only as otherwise authorized by law or with my written authorization which I may
revoke except to the extent information or actions have already been taken.