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Michigan Family Physicians

Privacy Notice

At this Facility, we respect the privacy and confidentiality of your health information. This Privacy Notice describes how we may use and disclose your medical/health information. This Notice applies to uses and disclosure we may make of your health information whether created or received by us. By law, we are required to maintain the privacy of your health information and provide you with notice of our legal duties and privacy practices.

Right to Notice

Under the Health Insurance Portability and Accessibility Act (HIPAA). Michigan Family Physicians can use your protected health information for treatment, payment and health care operations. a.) Treatment – We may use or disclose your health information to a physician or other healthcare provider providing treatment to you. b.) Payment – We may use or disclose your health information to obtain payment for services we provide you. c.) Health Care Operations – We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competency or qualifications of healthcare professionals, evaluating provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Your Authorization

Most uses and disclosures that do not fall under treatment, payment, health care operations will require your written authorization. Upon signing, you may revoke your authorization (in writing) through our practice at any time. Emergency Situations In the event of your incapacity or an emergency situation, we will disclose health information to a family member, or another person responsible for your care, using our professional judgment. We will only disclose health information that is directly relevant to the person’s involvement with your healthcare.


We will not use your health information for marketing communications without your written authorization.

Required by Law

We may also use or disclose your health information when we are required to do so by law. We may disclose information in response to a subpoena, discovery request or other lawful process. Risk to Public Health We may disclose your health information when required by law to prevent, control, or report disease, injury or disability. To collect or report adverse events and product defects, track Food and Drug Administration (FDA) regulated products; enable product recalls, repairs or replacements and review.

Abuse or Neglect

We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your or other people’s health or safety. National Security

We may disclose the health information of Armed Forces personnel to military authorities under certain circumstances. We may disclose health information to authorized federal officials required for lawful intelligence, counterintelligence and other national security activities. We may disclose health information of inmates or patients to the appropriate authorities under certain circumstances.

For Organ Donation or to Coroners, or Funeral Directors

We may disclose your health information such as for organ, eye or tissue donations; identification purposes; performing other duties authorized by law. Appointment Reminders We may use or disclose your health information to provide you with appointment reminders via phone, e-mail or letter.

Your Rights as a Patient

You have the right to restrict the disclosure of your protected health information (in writing). The request for restriction may be denied if the information is required for treatment, payment or health care operations. You have the right to receive confidential communications regarding your protected health information. You have the right to receive an account of disclosure of your protected health information. You have the right to a paper copy of this notice of privacy practices.Amend Information

Privacy Notice

You have the right to request we amend your protected health information. A request for an amendment must be in writing and it must explain why the information should be amended. Under certain circumstances, we may deny you request. Medical Records You have the right to see and copy your medical records and other records used to make treatment and payment decisions about you. You must submit a written request. We may charge you a fee for copying, mailing or other costs in complying with your request. We many deny your request to see or copy of your protected health information if, in our professional judgment, that access requested is likely to endanger life or safety of you or another person. You have the right to request a review of this decision

Legal Requirements

Michigan Family Physicians is required by law to maintain the privacy of your protected health information. We are required to abide by the terms of this notice as it is currently stated, and reserve the right to change this notice. The policies in any new notice will not be in effect until they are posted and available within our office. Complaints

If you have complaints regarding the way your protected health information was handled, you may submit a complaint in writing to our office. You will not be retaliated against in any manner for a complaint. Contact Information For further information about Michigan Family Physician’s privacy policies, please contact the Privacy Officer at the following address or phone number: Michigan Family Physicians, Attn: Privacy Officer, 400 N. Wayne Rd. Westland, MI 48185

Ph: 734-522-7000



I acknowledge that I have received the Notice of Privacy Practices of Michigan Family Physicians.


Patient or Personal Representative’s SignatureDate

If Personal Representative’s signature appears above, please describe Personal Representative’s relationship to the patient: ____________________________________.

Please list any individual (family member, friend) that takes part in your medical care and Dr. Colton and his Staff have permission to discuss your medical condition and possible treatment plans with.  If no one is listed below, we will only be able to discuss your care with you personally and not your spouse or other designated person.






Patient’s SignatureDate

This form will remain in power until revoked in writing by patient.