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.

If you have any questions or need help understanding this Notice, please contact our Privacy Officer. The contact information for the Privacy Officer is listed on the last page of this document.


You will be asked to sign a form stating you have received this notice. If you’re a minor under the age of 18 years old, your parent or guardian will sign on your behalf. We want you to understand your privacy rights and how we might use your Protected Health Information (PHI).  You do not have to sign the form. If you decide you do not want to sign it, we will still give you the services you need, and will still use your (PHI) when we need to.

In the rest of this Notice, we will use “PHI” to mean “protected health information”, and “release” to mean “disclose”.


“Minor” means an individual under the age of 18 years, this includes child and adolescent.

“Guardian” means a person appointed by the court to exercise specific powers over an individual who is a minor, legally incapacitated, or developmentally disabled.

“You” means an individual receiving services through CNS Healthcare, this includes adults and minors. If you’re a minor under the age of 18 years old, your parent or legal guardian will be acting on your behalf of this notice.


This notice describes CNS Healthcare’s practices regarding your protected health information.  


“Protected health information” is:

    • Information about you that may identify you and


  • relates to your past, present or future physical or mental health or condition, and


  • health care services related to your health or condition.   

Examples of this may include:

  • Your name, address, telephone number, and date of birth
  • Your diagnosis (the condition for which you are receiving treatment)
  • Your treatment plan and goals
  • Your progress toward those goals.

CNS Healthcare is required by law to do the following:

    • Make sure your protected health information is kept secure and private.
    • Let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
    • Give you this notice of our legal duties and privacy practices related to the use and disclosure of your protected health information.
    • Follow the terms of the notice currently in effect.
    • Let you know about any changes in the notice.

We may change our notice at any time.  The new notice will cover all PHI that we keep at the time of the new notice.  The new notice will be posted on our website, You can also call our office and ask us to send you a copy in the mail, or you can ask for one at the time of your next appointment.

This Notice of Privacy Practices describes how we may use and release (give to others) your PHI.  We may use it to carry out treatment, payment or health care operations. We may also use it for other purposes that are permitted or required by law.  This notice also describes your rights to see and control your PHI.

How We May Use or Release Your PHI:

Your PHI may be used and released to help us provide you with health care services. This includes services that you get from your treating professional(s), and our other staff. It can also include others outside of our offices that are involved in your care and treatment. It may also be used and released to pay your health care bills and to help our agency do its work.

Here are examples of the types of uses and releases of your PHI that our office can make. These examples are not a complete list, but they describe the types of uses and releases that we might make.

  1. Treatment:  We will use and release your PHI when we are giving you services.  We will also release your PHI when we are helping you get other services you need.  For example, we would release needed parts of your PHI to a home health agency that we contract with that gives you care.  
  2.  Payment:  We will use the parts of your PHI needed to get payment for your health care services.  Some of the reasons we would use your PHI are:
  • Finding out if your insurance will pay for the kind of service you are asking for.
  • Making sure services you get are medically necessary.
  • Evaluating how we use various services.

For example, getting approval for a hospital stay may require that your PHI be released to your insurance company or Oakland Community Health Network (OCHN).

  1.  Healthcare Operations:  We may use or release your PHI in order to support the business activities of this agency. If this is necessary, your information will be de-identified, unless the information is required by law. This means that no identifying information about you, such as your name or address, will be included. These activities include such things as:
  • Making sure we meet important goals and standards
  • Judging how well our employees do their job
  • Training workers and volunteers
  • Licensing or accreditation of our agency.

We may also use your PHI for carrying out other business activities. For example, we may release your PHI to volunteers or interns that see consumers at our agency.  We may also use a sign-in sheet at the registration desk where you will be asked to sign your name, and/or call you by name in the waiting room. We may use or release your PHI, such as your name and address, to contact you to remind you of your appointment.

We will share your PHI with outside (third-party) “business associates” that perform different kinds of activities for our agency.  For example, we might use an outside computer company to help us with our computer records. Whenever an arrangement like this involves the use or release of your PHI, we will have a written contract (Business Associate Agreement) with that organization that will protect your privacy.

We may use or release parts of your PHI to offer you information that may be of interest to you.  For example, we may use your name and address to send you newsletters or other information about activities of our agency or Oakland Community Health Network (OCHN).  You may contact our Privacy Officer to ask that these materials not be sent to you.

CNS Healthcare may use some of your PHI for certain fundraising activities but we will obtain a written authorization from you when we do this.  We may use your photo or other PHI on our Facebook page or in our newsletters.

We may use your PHI to help us determine what other services we or our business partners may be of interest to you. For example, your name and address may be used to send you newsletters, invitations, announcements or general communications about upcoming seminars, or health fairs,  We may also send you information based on your own health concerns. We do not receive monies from these third parties for making this communication and if we ever did, we would receive your written authorization first.

You can at any time tell us not to contact you again, or you at any time can “opt out” of being contacted for any fundraising or marketing activities we may be participating in. This in no way will affect your treatment or payment.

We do not sell your information to anyone and do not manage or create a hospital directory.

We do not create psychotherapy notes. We will only release substance abuse treatment records when you sign an authorization for us to do so.

Other Permitted and Required Uses and Releases

We may use or release your PHI in the following situations required by law without your consent or authorization.  

  1. Public Health:  We may release parts of your PHI for public health purposes when the law requires us to do so. The release will only be made for the purpose of preventing disease, helping with medication recalls, reporting adverse reactions to medications, reporting suspected abuse, neglect, or domestic violence and preventing or reducing a serious threat to anyone’s health or safety.
  2. Health Oversight:  We may release your PHI to agencies that are responsible for making sure our services meet quality standards.  They may need your PHI for activities such as audits, investigations, and inspections. Agencies that use this information include the Center for Medicare and Medicaid Services, the Michigan Department of Community Health, and Oakland Community Health Network (OCHN). If requested, we must release your PHI to the Department of Health and Human Services so they can make sure we are following the law.
  3. Legal Proceedings:  If we are court or administratively ordered to do so, or if it is needed to meet legal requirements, we may release PHI for any court or administrative proceeding.  In this case, your PHI may be disclosed unless prohibited by State or Federal law.
  4. Law Enforcement:  We may also release PHI for law enforcement purposes. These may include:
  • To help identify or locate victims of a crime
  • If a death may have occurred as a result of a crime
  • If a crime occurs on the property of our agency
  • If there medical emergency not on the Agency’s property where it is likely that there has been a crime.
  1. Coroners or Medical Examiners:  We may release PHI to a coroner or medical examiner to help identify someone, to determine the cause of death or for the coroner or medical examiner to perform other duties.
  2. Criminal Activity: If you tell your treating professional that you are going to harm another person we may release your PHI to the police and the person you threaten to harm
  3. Workers’ Compensation:  We may release Your PHI to comply with workers’ compensation laws and other similar programs.
  4. Inmates:  We may use or release your PHI if you are an inmate of a correctional facility and this agency created or received your PHI in the course of providing care to you. In this situation, the request for PHI would need to be initiated by the correctional facility. The reasons this could be necessary are:
    • For the facility to provide you with health care,
    • For your health and safety or the health and safety of others, or
    • For the safety and security of the correctional facility
  1. Abuse or Neglect:  We will release your PHI to the Michigan Family Independence Agency if we think a minor or a vulnerable adult has been abused or neglected. Federal and state laws require these reports.  Michigan law does not require us to notify you when we make a report about Abuse or Neglect.

Uses and Disclosures of Protected Health Information Based On Your Written Authorization

You must give us special permission by signing a form called an authorization for any use or release of your PHI that is not covered in this Notice of Privacy Practices that we just described.  

You may cancel this authorization in writing at any time, unless our agency has already released your PHI based on an authorization you gave us.

You have the right say how we can use or disclose your PHI.  

There are two times when your treating professional is allowed to use their professional judgment to decide if a use or release is in your best interest:

  1. Emergencies:  We may use or release your PHI in an emergency treatment situation.  
  2. Communication Barriers:  If you are an adult (18 years of age or older) and do not have a guardian, we may use and release your PHI if someone at our agency tries to get consent from you but cannot because of substantial communication barriers.

“Substantial communication barrier” means that a person does not use any kind of speech, or other type of communication such as a body signal like blinking of the eyes for yes or no. Your treating professional may use their professional judgment to decide if you mean to agree to this use or release. If they do, they must follow these rules:

  • A witness who does not work for this agency (preferably a family member or advocate) agrees that you cannot give consent.
  • The witness signs a written statement agreeing that you were unable to give any type of consent. They must also give the reason why this is true.

In these cases, only the PHI that is important for your health care will be released.

The only time we would not need an authorization is if the use or release is permitted or required by state law.  We have already described these situations in the section “Other Permitted and Required Uses and Releases”.


Following is a statement of your rights regarding your PHI and a brief description of how you may use these rights.

  1. You have the right to inspect and copy your protected health care information.  This means you may look over and get a copy of your electronic or paper PHI that is held in a designated record set for as long as we maintain the PHI.  “Designated record set,” means medical and billing records we use in making decisions about you.

Under federal law, however, you may not see or copy the following records:

  • Psychotherapy notes (we don’t use these)
  • Information we have gathered for use in court or at hearings
  • PHI that is covered by a law that states you may not see it

You may have a right to have this decision reviewed.  Please contact our Privacy Official if you have questions about seeing or copying your medical record.

We will provide you with a copy or a summary of your PHI, within 30 days of your request if not sooner.

  1. You have the right to ask us to not release parts of your protected health care information.  This means you may ask us not to use or release any part of your PHI for treatment, payment or healthcare operations purposes.  You may also ask that any part of your PHI not be released to others who may be involved in your care, or for other purposes we have described.  You must tell us in writing what parts of your PHI you do not want released, and to whom you do not want it released.

We are not required to agree to your request and may say “no” but we’ll tell you why.  We will allow your PHI to be used or released if your treatment professional believes it is in your best interest. If your treatment professional does agree to your request, we will only use or release your PHI if it is needed to provide emergency treatment.  Please discuss any restriction you want to ask for with your treating professional.

However if you pay for a service or health care item out of pocket in full, you can ask us not to share that information for the purpose of payment, or our operations with your health insurers. We will say “yes” unless a law requires us to share that information.”

  1. You have the right to request to receive confidential communications from us by another means or at another location.  For instance, you can ask us to send mail from our office to your Post Office box instead of your home address or contact you on your cell phone instead of your home phone.  We will go along with reasonable requests. We will not ask you why you want this change. Please make this request in writing to your case manager or our Privacy Officer.
  2. You have the right to be told of any releases we have made of your PHI to whom and why.  This right does not apply to releases for treatment, payment or healthcare operations that we have described.  It also does not apply to releases we may have made to you or others involved in your care, or for notification purposes.  You have the right to be told about releases that happen after April 14, 2003 and for 6 years prior to the date you’ve asked for it.  There are rules that may limit your right to receive some kinds of information. You are entitled to one accounting per year. Please contact our Privacy Officer if you have questions.
  3.  You have the right to request an amendment to your protected health care information.  If you believe that the information we have about you is incorrect or incomplete, you may ask to put the correct information in your record, ask us how to this this. We may say “no” to the request to amend, but we will tell you why in writing within 60 days of your request.

We can only correct information that we created or that was created on our behalf. If you believe that information we have received from another provider or source is wrong, you must ask that provider or agency to change it.

  1. You have a right to give someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

We will make sure the person has this authority and can act for you before we take any action.

  1. You have a right to be notified when there has been a reportable breach to your PHI. We will notify you in writing of what information was breached, what we have done to protect your PHI from further unauthorized disclosure, who you may contact for further information or assistance in how to request free credit reports, how to place a fraud alert, and how put creditors on alert.


For certain PHI you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, let us know. We will be sure to have you sign an authorization allowing for that disclosure on file that will be good for a year.

  1. Share information with your family, close friends or others involved in your care
  2. Share information in a disaster relief situation


You can complain if you feel we have violated your rights by contacting us using the information below.  We will not retaliate against you for filing a complaint. You may reach our Privacy Officer at:

Privacy Officer

CNS Healthcare

279 Summit Drive

Waterford, Michigan 48328

Phone: 248 409-4175

Or you may contact the U.S. Department of Health and Human Services.


Office for Civil Rights

U.S. Department of Health & Human Services

233 N Michigan Ave., Ste. 240

Chicago, IL 60601

(312) 886-2359 TDD: (312) 353-5693

Fax: (312) 886-1807

This notice was published and becomes effective on April 14, 2003.

Revised 04/18, 09/16, 04/15, 11/14, 12/13, 09/13, 08/08

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