NOTICE OF PRIVACY PRACTICES PURSUANT TO THE HEALTH INFORMATION PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)
NOTICE OF PRIVACY PRACTICES PURSUANT TO THE
HEALTH INFORMATION PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)
I. INTRODUCTION.
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. This Notice of Privacy Practices (Notice) applies to all
information about care that you receive from the following:
EVERLIV HEALTH and its organized health care arrangements where the Providers
participates in quality improvement and assessment activities as part of an organized health care
arrangement where the providers work jointly to help improve the quality of your care. For
questions or complaints by phone or mail, please use the following contact:
Everliv Health, PLLC
300 E Maple Rd, Suite 340
Birmingham, MI 48009
248-731-4100
In addition to the above, this Notice applies to other portions of [EVERLIV HEALTH] that
support the health care activities and our providers. All of these entities may use and share your
health information for treatment, payment or health care operations as described in this Notice.
In this notice, your health information means your substance use disorder patient record.
II. Your Information. Your Rights. Our Responsibilities.
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.
Your Rights
You have the right to:
• Get a copy of your paper or electronic medical record
• Correct your paper or electronic medical record
• Request confidential communication
• Ask us to limit the information we share
• Get a list of those with whom we’ve shared your information
• Get a copy of this privacy notice
• Choose someone to act for you
• File a complaint if you believe your privacy rights have been violated
Your Choices
You have some choices in the way that we use and share information as we:
• Tell family and friends about your condition
• Provide disaster relief
• Include you in a hospital directory
• Provide mental health care
• Market our services and sell your information
• Raise funds
Our Uses and Disclosures
We may use and share your information as we:
• Treat you
• Run our organization
• Bill for your services
• Help with public health and safety issues
• Do research
• Comply with the law
• Respond to organ and tissue donation requests
• Work with a medical examiner or funeral director
• Address workers’ compensation, law enforcement, and other government
requests
• Respond to lawsuits and legal actions
To the extent that we have your substance use disorder patient records, subject to
42 CFR part 2, we will not share that information for investigations or legal
proceedings against you without (1) your written consent or (2) a court order and a
subpoena.
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, office, or cell 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,” for
example, if it could affect your care. If we agree to your request, we may still share this
information in the event that you need emergency treatment.
• 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.
Get a list of those with whom we’ve shared information
• You can ask for a list (accounting) of the times we’ve shared your health information for
six years prior to the date you ask, who we shared it with, and why.
• We will include all the disclosures except for those about treatment, payment, and health
care operations, and certain other disclosures (such as any you asked us to make). We’ll
provide one accounting a year for free but will charge a reasonable, cost-based fee if you
ask for another one within 12 months.
Get a copy of this privacy notice
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the
notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
• If someone has authority to act as your personal representative, such as if someone has
your 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 https://www.hhs.gov/hipaa/filing-a-
complaint/index.html.
• 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 or
payment for 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
• Sale of your information
• 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.
If we have your substance use disorder patient records, subject to 42 CFR part 2, we will give
you clear and obvious notice in advance and a choice about whether to receive fundraising
communications that use your Part 2 information.
III. 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.
In all cases, including those listed below, if we have substance use disorder patient records
about you, subject to 42 CFR part 2, we cannot use or share information in those records in civil,
criminal, administrative, or legislative investigations or proceedings against you without (1) your
consent or (2) a court order and a subpoena.
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.
With your consent, we may also use and share your information in the following ways:
To whomever you name in a consent to share your information
To prevent multiple enrollments in withdrawal management or maintenance treatment
programs
To report participation in treatment required by the criminal justice system
To report prescribed substance use disorder treatment medications to a state prescription
drug monitoring program when required by law.
Redisclosure According to HIPAA
When you consent to uses and disclosures for all future treatment and payment purposes and to
run our business, we may share your information with other substance use disorder treatment
programs, doctors’ offices, and health care businesses for those activities. If the person who
receives it is subject to HIPAA, then they are allowed to use and share your information again
without your consent for the purposes that HIPAA allows. Your information still cannot be used
in legal proceedings against you unless (1) you consent or (2) based on a Part 2 court order and a
subpoena (or similar legal requirement).
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 in this notice
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.
E. WHO YOU CAN CONTACT FOR INFORMATION ABOUT THIS NOTICE OR OUR
PRIVACY PRACTICES. If you have questions about this Notice or complaints about our
privacy practices, or if you would like to know how to file a complaint with the Office for Civil
Rights of the U.S. Department of Health and Human Services, you can contact our Privacy
Director at [PHONE NUMBER]. You will not be penalized for filing your complaint.
We may change our privacy practices at any time pursuant to regulatory changes, updates in
statute, and legal guidance. EVERLIV HEALTH adheres to all local, state, and Federal
guidelines and agencies. This includes, but is not limited to HIPAA, HITECH, the Office of
Civil Rights (OCR), and state-equivalent guidelines in the State of Michigan for privacy
laws and protections, including compliance in healthcare privacy.
I understand that the failure to sign/submit this authorization or the cancellation of
this authorization will not prevent me from receiving any treatment or benefits I am entitled to
receive, provided this information is not required to determine if I am eligible to receive those
treatments or benefits or to pay for the services I receive.
Patient Signature Patient Printed Name:_________________________________________
Date:_______________________________________
EFFECTIVE DATE OF THIS NOTICE: April 14, 2003, last revised February 2026.
© Everlivhealth.com
300 E Maple Rd
Suite 340
Birmingham, MI 48009