Notice of HIPPA

Counseling Behavioral Center

44899 Centre Court, Ste. 101 Clinton Twp., MI 48038
Phone: 586-690-8331 | Fax: 586-690-8401

Notice of HIPPA Privacy Practices/Client Bill of Rights


(Download PDF Copy).

Effective Date of this Notice: March 24, 2014
If you have any questions regarding this notice or our health information privacy policies, please contact our:
  • Privacy officer - phone: (586) 792-1654
  • Corporate Compliance Officer - phone: (586) 792-1654

Your Rights
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record

  • You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
  • We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your medical record
  • You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
  • We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

  • You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
  • We will say “yes” to all reasonable requests.

Ask us to limit what we use or share

  • You can ask us not to use or share certain health information for treatment, payment, or our operations.
    We are not required to agree to your request, and we may say “no” if it would affect your care.
  • 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 insurer. We will say “yes” unless a law requires us to share that information.
Choose someone to act for you
  • If you have given 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.

File a complaint if you feel your rights are violated

  • You can complain if you feel we have violated your rights by contacting us using the information on page 1.
  • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting
  • We will not retaliate against you for filing a complaint.
Your Choices
For certain health information, 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, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

  • Share information with your family, close friends, or others involved in your care
  • Share information in a disaster relief situation
  • Include your information in a hospital directory
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

  • Marketing purposes
  • Most sharing of psychotherapy notes

In the case of fundraising:

  • We may contact you for fundraising efforts, but you can tell us not to contact you again.

Our Uses and Disclosures
How do we typically use or share your health information?
We typically use or share your health information in the following ways.

Treat you

We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization
We can use and share your health information to run our practice, improve your care, and contact you when necessary.
Example: We use health information about you to manage your treatment and services.

Bill for your services
We can use and share your health information to bill and get payment from health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your services.<

How else can we use or share your health information?
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see:

Help with public health and safety issues
We can share health information about you for certain situations such as:

  • Preventing disease
  • Helping with product recalls
  • Reporting adverse reactions to medications
  • Reporting suspected abuse, neglect, or domestic violence
  • Preventing or reducing a serious threat to anyone’s health or safety

Do research
       We can use or share your information for health research.

Comply with the law
         We will share information about you if state or federal laws require it, including with the Department of Health and
          Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests
        We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director
        We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests
We can use or share health information about you:

  • For workers’ compensation claims
  • For law enforcement purposes or with a law enforcement official
  • With health oversight agencies for activities authorized by law
  • For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions
        We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Our Responsibilities

  • We are required by law to maintain the privacy and security of your protected health information.
  • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
  • We must follow the duties and privacy practices described in this notice and give you a copy of it.
  • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
  • We never market or sell personal information.

For more information see:

Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you.
The new notice will be available upon request, in our office, and on our web site.

Substance Abuse Treatment and Privacy
If you are receiving substance abuse treatment, you have other rights related to your privacy.
Your alcohol and drug abuse treatment records are protected by Federal Law and regulations such as the Confidentiality of Alcohol and Drug Client Information Act (42CRF Part 2). Generally, this means we will never share any substance abuse treatment information without your written permission, except as permitted by law.

Client Bill of Rights
You have the right to:

  • Get respectful treatment that will be helpful to you.
  • Have a safe treatment setting, free from sexual, physical, and emotional abuse.
  • Report immoral and illegal behavior by a therapist.
  • Ask for and get information about the therapist’s qualifications, including his or her license, education, training, experience, membership in professional groups, special areas of practice, and limits on practice.
  • Have written information, before entering therapy, about fees, method of payment, insurance coverage,
    number of sessions the therapist thinks will be needed, substitute therapists (in cases of vacation and emergencies)
    and cancellation policies.
  • Refuse audio or video recording of sessions (for training purposes).
  • Refuse to answer any question or give any information you choose not to answer or give.
  • Know if your therapist will discuss your case with others (for instance, supervisors, consultants, or students).
  • Ask that the therapist inform you of your progress.
I have read, discussed, and understand the Notice of HIPPA Privacy Practices/Client Bill of Rights. My signature below affirms that I understand my rights, and that I know to contact the Privacy Officer and/or Corporate Compliance Officer (see pg. 1) with any questions.

Consumer: ______________________________________________                              Date: _________________

Printed Name: _____________________________________                                                           


Guardian: _______________________________________________                             Date: _________________

Printed Name: ___________________________________________                                             


Witness: _______________________________________________                               Date: _________________

Printed Name: ___________________________________________