Family Health Center notice of privacy practices
Blue Care Network of Michigan understands the importance of keeping your health information private. We follow strict privacy policies in accordance with state and federal law. For example, we never sell your health information to anyone, or release it to any company who may want to sell products to you.
For more information about our privacy practices, call 313-225-9000.
Our Notice of Privacy Practices (26K PDF) details our privacy practices and your rights with respect to the handling of your personal information in accordance with the Health Insurance Portability & Accountability Act.
Forms
- Authorization Form — Protected Health Information (PDF)
- Download and complete this form to approve the release of your protected health information to an entity of your choice.
- Authorization Form — Psychotherapy Notes (PDF)
- Download and complete this form to approve the release of your psychotherapy health information to an entity of your choice.
- Authorization Revocation Form (PDF)
- Download and complete this form to revoke authorization for disclosure of your health information.
- Access Form (PDF)
- Download and complete this form to request access to specific information that we maintain about you.
- Amendment Form (PDF)
- Download and complete this form to append the information we maintain about you with additional information that you provide.
- Restriction Request Form (PDF)
- Download and complete this form to request restrictions on the way in which we handle your health information.
- Confidential Communications Form (PDF)
- Download and complete this form to request that we use an alternative address or communication mechanism to exchange health information with you.
- Accounting of Disclosures Form (PDF)
- Download and complete this form to request a listing of the specific disclosures that we have made to others of your health information, with certain exceptions.
- Privacy Complaint Form (PDF)
- Download and complete this document if you believe that we have misused your health information in any way that violates your privacy. Alternatively, you can report misuse of your health information to our privacy complaint line: 800-552-8278 or file your complaint directly with the Office for Civil Rights at the following address:
Office for Civil Rights
U.S. Department of Health & Human Services
233 N. Michigan Ave., Ste. 240
Chicago, IL 60601
312-886-2359; 312-353-5693 (TDD)
312-886-1807 FAX
page modified 03/20/2009