Understanding the Type of Information We Have. Protected Health Information (PHI) consists of all individually identifiable information that is created or received by Northern Lakes Community Mental Health Authority (the “Authority”) that relates to your past, present or future physical or mental health or condition, to your treatment, and to payment for treatment. It includes your date of birth, sex, ID number and other information. We also bill for services provided, receive reports from your doctor and other data about your health care.

Our Privacy Commitment To You. We care about your privacy. The information we collect about you is private. We are required to give you a notice of our privacy practices, to follow these practices, and to notify affected individuals following a breach of unsecured protected health information. Only people who have both the need and the legal right may see your information.

How We May Use and Disclose Your Protected Health Information. We may use and disclose PHI for a variety of reasons. We have limited right to use and/or disclose your PHI without your authorization for purposes of treatment, payment or our health operations. Other uses and disclosures require your written authorization unless the law permits or requires us to make the use of disclosure without your authorization. If we disclose your PHI to a third party in order for that third party to perform a function on your behalf, the third party must agree that it will extend the same degree of privacy protection to your PHI that we do.
Generally speaking, we limit disclosures to third parties of your PHI to the information we believe is necessary for purposes of treatment, payment or health care operations by the third party. We will disclose a complete set of your PHI to a third party only if: (1) a complete set is necessary for treatment; (2) you have requested us to us to supply a complete set; (3) we are required by law to provide a complete set.

Treatment – We may disclose health information about you to coordinate your health care.
Payment – We may use and disclose information so the care you get can be properly billed and paid for.
Health Care Operations – We may need to use and disclose information to operate the program.
Health Care Organizations – We may use or disclose your PHI in order to improve quality and efficiency of our services.
Informational Purposes – We may use your PHI to give you helpful information such as alternative treatment choices, program benefit updates, and consumer protection information.
Appointment Reminders – We may use or disclose your PHI in order to contact you and remind you of a scheduled appointment.
Government Entities Providing Benefits – We may use or disclose your PHI to other government entities as necessary for you to apply for and receive additional benefits and services.
Exceptions – For certain kinds of records, such as psychotherapy notes, your permission may be needed even for release for treatment, payment and health care operations.
As Required By Law – We will release information when we are required by law to do so.
With Your Permission – If you give us permission in writing, we may use and disclose your health information. If you give us permission, you have the right to change your mind and revoke it. This must be in writing, too. We cannot take back any uses or disclosures already made with your permission. With your consent, we may notify or release information about you to a friend or family member who is involved in your care.

Business Associates: There are some services provided in our organization through contracts with Business Associates. To protect your health information, however, we require the business associate to appropriately safeguard your information.
Research: Information will not be provided to researchers without your signed informed consent, or unless the research has been approved by an institutional review board or a privacy board and the researchers ensure the privacy of your information.
Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.
Workers Compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.
Public Health: As authorized by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
Law Enforcement: We may disclose health information for law enforcement purposes as required by law or in response to a valid court order.
Victims of Abuse, Neglect, or Domestic Violence: We may disclose information about you to a government authority, such as a social service or protective agency, if we reasonably believe you are a victim of abuse, neglect, or domestic violence. We will only disclose this type of information to the extent required by law, if you agree to the disclosure, or if the disclosure is allowed by law and we believe it is necessary to prevent serious harm to you or someone else.
To Avert a Serious Threat To Health or Safety: If there is a compelling need, we may disclose information to prevent a serious threat to your health or safety or the health and safety of the public or another person.
Health Oversight: We may disclose health information to a health oversight agency for activities authorized by law.
Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be necessary for the institution to provide you with health care; to protect your health and safety or the health and safety of others; or for the safety and security of the correctional institution.
Special Situations: Consistent with applicable law, we may disclose health information to funeral directors, coroners, medical examiners; as required by military command authorities; and for national security activities. A mental health services recipient’s information will be disclosed only as allowed under Michigan law.
If we use or disclose your information for any purpose that is not described in this notice, we will do so only with your permission.

You have the following rights regarding the health information that we have about you. Your requests must be made in writing to the Northern Lakes Community Mental Health Authority at the address below. You have a right to:
Inspect and Copy – In most cases, you have the right to look at or get copies of your records. You may be charged a fee for the cost of copying your records.
Amend – You may ask us to change your records if you feel that there is a mistake. We can deny your request for certain reasons, but we must give you a written reason for our denial.
A List of Disclosures – You have the right to ask for a list of disclosures made in the six years before the date of your request. This list will not include the times that information was disclosed for treatment, payment, or health care operations. The list will not include information provided directly to you or your family, or information that was sent with your permission.
Request Restrictions on Our Use or Disclosure of Information – You have the right to ask for limits on how your health information is used or disclosed. We are not required to agree to such requests unless (1) the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law and (2) the protected health information pertains solely to a health care item or service for which you, or a person other than a health plan on your behalf, has paid us in full. We will notify you if we are unable to agree to a requested restriction.
Request Confidential Communications – You have the right to ask that we share information with you in a certain way or in a certain place. For example, you may ask us to send information to your work address instead of your home address. We may deny your request unless you clearly state your safety is at risk.
Revoke Authorization – If you give us permission to use or disclose your health information, you have the right to change your mind and revoke it. This must be in writing. We cannot take back any uses or disclosures already made with your permission.

Changes to this Notice
We reserve the right to revise this notice. A revised notice will be effective for health information we already have about you as well as any information we may receive in the future. We are required by law to comply with whatever notice is currently in effect. Any changes to our notice will be published on our website. Go to, click on Assistance Programs, then Health Care Coverage, and look under Protected Medical Information (HIPAA). If the changes are material, a new notice will be mailed to you before it takes effect.

How to Use Your Rights Under this Notice
If you want to make a Privacy Rights request or file a complaint, your request or complaint must be in writing. If you are writing a complaint, tell us your name (and the name of the person affected, if you are filing the complaint for another person), identification number, what right you believe was violated, who you believe committed the violation, what you want done to correct the problem, and an address and telephone number were you can be contacted.

Requests and complaints should be sent to:
Privacy Officer
Northern Lakes Community Mental Health Authority
105 Hall Street, Suite A, Traverse City MI 49684

You also have the right to file a complaint with the federal government. Written complaints should be sent to:
Office for Civil Rights, U.S. Department of Health and Human Services, 233 N. Michigan Ave., Ste. 240, Chicago, IL 60601
Phone: 312-886-2359 or 800-368-1019, TDD: 800-537-7697, FAX: 202-619-3818, Email:

You will not be penalized or retaliated against for filing a complaint with either MDHHS or the federal government.

Copies of this Notice – You have the right to receive an additional copy of this notice at any time. Please call or write to us to request a copy.

NOTE: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1-800-337-8598 (TTY: 711)

Northern Lakes Community Mental Health Authority complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

Notice of Privacy Practices Effective May 2020
This notice of Privacy Practices is effective until further notice.

Printable version of this Notice of Privacy Practices