Notification if a Breach of your Medical Information Occurs: You have the right to be notified in the
event of a breach of medical information about you. If a breach of your medical information occurs, and if that
information is unsecured (not encrypted), we will notify you promptly with the following:
• A brief description of what happened;
• A description of the health information that was involved;
• Recommended steps you can take to protect yourself from harm;
• What steps we are taking in response to the breach; and,
• Contact procedures so you can obtain further information.
A Paper Copy of This Notice: You have the right to a paper copy of this notice. You may ask us
to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you
are still entitled to a paper copy of this notice.
You may visit our website (www.mypccadocs.com) and print or view a copy of
this notice by clicking on the Notice of Privacy Practices link found under the About Us tab.
To exercise any of your rights, please obtain the required forms from the practice’s Privacy Officer and submit
your request in writing.
CHANGES TO THIS NOTICE
We reserve the right to change this notice and the revised or changed notice will be effective for information we
already have about you as well as any information we receive in the future. The current notice will be posted in
the practice and on our website and include the effective date.
If you believe your privacy rights have been violated, you may file a complaint with the
Privacy Officer at this practice or with the Secretary of the Department of Health and Human Services. All
complaints must be submitted in writing.
You will not be penalized for filing a complaint.
OTHER USES OF HEALTH INFORMATION
Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be
made only with your written authorization. If you provide us permission to use or disclose health information about
you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no
longer use or disclose health information about you for the reasons covered by your written authorization. You
understand that we are unable to take back any disclosures we have already made with your authorization, and that
we are required to retain our records of the care that we provided to you.
PRIVACY OFFICER CONTACT INFORMATION
Practice Privacy Officer: Sandra Lange
Mailing Address: 50505 Schoenherr Road, Suite 290, Shelby Township, MI 48315
Telephone Number: 586-314-0080