Co-Parenting Solutions, LLC

5. Notice of Privacy


It is important to read and understand this Notice of Privacy Practices before signing the consent and Acknowledgement Form.

If you have any questions about this Notice or would like further information concerning your privacy rights, please contact Jordana Wolfson, LMSW.

Your health record contains information about you that has been created and received by us, including demographic information, that may reasonably identify you and that relates to your past, present or future physical or mental health or condition, or payment for the provision of related health care services. This information is referred to as Protected Health Information (“PHI”).

This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law, including the Health Insurance Portability and Accountability Act (“HIPAA”), regulations promulgated under HIPAA including the HIPAA Privacy and Security Rules, and the NASW Code of Ethics. It also describes your rights to access and control your PHI and certain obligations we have regarding the use and disclosure of your PHI.

We are required by law to maintain the privacy of PHI and to provide you with a Notice of our legal duties and privacy practices with respect to your PHI and to abide by the terms of this Notice that is currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that is maintained by us. If you would like to receive a copy of any revised Notice you should access our web site at, or ask at your next appointment.

Contact With You. If you provide a phone contact, text capable phone, and/or email address, such contact may be used for communication, scheduling or therapeutic purposes. CoParenting Solutions shall not be held liable for an incorrect phone number or email address provided by you, or if a person other than you accesses your phone or emails.


For Treatment. Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. We may disclose PHI to any other consultant only with your authorization. If we are permitted to do so, we may also disclose your PHI to individuals or facilities that will be involved with your care after you leave our practice and for other treatment reasons. We may also use or disclose your PHI in an emergency situation.

For Payment. We may use and disclose PHI so that we can receive payment for the treatment services and related services provided to you. For billing and payment purposes, we may disclose your PHI to your payment source, including insurance or managed care company, Medicare, Medicaid, or another third party payor. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, we will only disclose the minimum amount of PHI necessary for purposes of collection.

For Health Care Operations. We may use or disclose, as needed, your PHI as necessary for the practice’s operation, including, but not limited to, quality assessment activities, employee review activities, auditing functions, licensing, and conducting or arranging for other business.

Business Associates. There may be some services provided by the practice’s business associates who provide computer, billing or transcription services to the practice or legal or accounting consultants. These companies and individuals are called business associates These companies and individuals are called business associates. For example, we may share your PHI with third parties that perform various business activities (e.g., billing or typing services) provided we have a written contract with the business that requires it to safeguard the privacy of your PHI. We may disclose your PHI to a business associate so that they can perform the job we have asked them to do. To protect your PHI, we require our business associates to enter into a written contract that requires them to appropriately safeguard your PHI. For training or teaching purposes PHI will be disclosed only with your authorization.

To Avert a Serious Threat to Health or Safety. We may use and disclose your PHI when necessary to prevent a serious threat to your health or safety or the health or safety of the public or another person.

Required by Law. We may disclose your PHI to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule.

Without Authorization. Following is a list of the categories of uses and disclosures permitted by HIPAA without an authorization. Applicable law and ethical standards permit us to disclose information about you without your authorization only in a limited number of situations.

Child Abuse or Neglect. We may disclose your PHI to a state or local agency that is authorized by law to receive reports of child abuse or neglect.

Judicial and Administrative Proceedings. We may disclose your PHI pursuant to a subpoena (with your written consent), court order, administrative order or similar process.

Deceased Patients. We may disclose PHI regarding deceased patients as mandated by state law, or to a family member or friend that was involved in your care or payment for care prior to death, based on your prior consent. A release of information regarding deceased patients may be limited to an executor or administrator of a deceased person’s estate or person identified as next-of-kin.

Medical Emergencies. We may use or disclose your PHI in a medical emergency situation to medical personnel in order to prevent serious harm. Our staff will try to provide you a copy of this notice as soon as reasonably practicable after the resolution of the emergency.

Family Involvement in Care. We may disclose information to close family members or friends directly involved in your treatment based on your consent or as necessary to prevent serious harm. If you are unable to agree or object to such a disclosure we may disclose such information if we determined that it is in your best interest based on our professional judgment or if we reasonably infer that you would not object. We may also use or disclose your information to family members that are directly involved in your treatment with your verbal permission.

Disaster Relief. We may disclose your PHI to a public or private entity authorized by law to assist in a disaster relief effort.

Health Oversight. If required, we may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies and organizations that provide financial assistance to the program (such as third-party payors based on your prior consent) and peer review organizations performing utilization and quality control.

Law Enforcement. We may disclose PHI to a law enforcement official as required by law, in compliance with a subpoena (with your written consent), court order, administrative order or similar document, for the purpose of identifying a suspect, material witness or missing person, in connection with the victim of a crime, in connection with a deceased person, in connection with the reporting of a crime in an emergency, or in connection with a crime on the premises.

Specialized Government Functions. We may review requests from U.S. military command authorities if you have served as a member of the armed forces, authorized officials for national security and intelligence reasons and to the Department of State for medical suitability determinations, and disclose your PHI based on your written consent, mandatory disclosure laws and the need to prevent serious harm.

Public Health. If required, we may use or disclose your PHI for mandatory public health activities to a public health authority authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, or disability, or if directed by a public health authority, to a government agency that is collaborating with that public health authority.

Public Safety. We may disclose your PHI if necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.

Research. PHI may only be disclosed after a special approval process or with your authorization.

Fundraising. We may send you fundraising communications at one time or another. You have the right to opt out of such fundraising communications with each solicitation you receive.

With Authorization. Uses and disclosures not specifically permitted or required by applicable law will be made only with your written authorization, which may be revoked by you at any time, except to the extent that we have already made a use or disclosure based upon your authorization. The following uses and disclosures will be made only with your written authorization: (i) most uses and disclosures of psychotherapy notes which are separated from the rest of your medical record, subject to our professional judgment; (ii) most uses and disclosures of PHI for marketing purposes, including subsidized treatment communications; (iii) disclosures that constitute a sale of PHI; and (iv) other uses and disclosures not described in this Notice of Privacy Practices.


You have the following rights regarding PHI we maintain about you. To exercise any of these rights, please submit your request in writing to our Privacy Officer at Co-Parenting Solutions, LLC c/o Jordana Wolfson, 31000 Telegraph Rd., Ste 280, Bingham Farms, MI 48025:

  • Right of Access to Inspect and Copy. You have the right, which may be restricted under certain circumstances, to inspect, access and obtain a copy of your PHI that is used to make decisions about your care for as long as the PHI is maintained by us.
  • Access, Inspection and Copying. Access, inspection and obtaining a copy of your PHI may be denied under certain circumstances. We may charge a reasonable, cost- based fee for copies. If your records are maintained electronically, you may also request an electronic copy of your PHI. You may also request that a copy of your PHI be provided to another person provided you submit an authorization to that affect. If we deny your request, we will provide you with a written explanation of the reason for the denial. You may have the right to have this denial reviewed under certain circumstances, in which case you will have the right to have this denial reviewed by an independent health care professional designated by us to act as a reviewing official. This individual will not have participated in the original decision to deny your request.
  • Right to Amend. If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information, although we are not required to agree to the amendment. Your request must be made in writing to us and must state the reason for the requested amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement and will provide you with a copy. Please contact the Privacy Officer if you have any questions.
  • Right to an Accounting of Disclosures. You have the right to request an accounting of certain of the disclosures that we make of your PHI. You must submit a request in writing, stating a time period beginning on or after April 14, 2003 that is within six (60 years from the date of your request. The first accounting within a twelve-month period will be free, otherwise we may charge you a reasonable, cost- based fee if you request more than one accounting in any 12-month period.
  • Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI You must submit a written request stating the specific restriction requested. We are not required to agree to your request. You may terminate the restriction if the other party is notified in writing of the termination. Unless you agree, the termination of the restrictions only effective with respect to PHI created or received after we have informed you of the termination. You may restrict disclosure of PHI to a health plan for purposes of carrying out payment or health care operations, and the PHI pertains to a health care item or service that you paid for out of pocket.
  • Right to Request Confidential Communication. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. We will accommodate reasonable requests. We may require information regarding how payment will be handled or specification of an alternative address or other method of contact as a condition for accommodating your request. You must submit a written request to restrict communications.
  • Breach Notification. If there is a breach of unsecured PHI concerning you, we may be required to notify you of this breach, including what happened and what you can do to protect yourself.
  • Right to a Copy of this Notice. You have the right to a written copy of this notice. In addition, you may obtain a copy of this Notice at our website,


If you believe we have violated your privacy rights, you have the right to file a complaint in writing with our Privacy Officer at Co-Parenting Solutions, LLC or with the Secretary of Health and Human Services at 200 Independence Avenue, S.W. Washington, D.C. 20201 or by calling (202) 619-0257. We will not retaliate against you for filing a complaint and will make every reasonable effort to resolve your complaint with you.

CoParenting Solutions, LLC

Jordana Wolfson, LMSW
Privacy Officer

31000 Telegraph Rd., Ste 280
Bingham Farms, MI 48025
Tel. – 248.330.5351

The effective date of this Notice is December 2019.

Notice of Privacy
Receipt and Acknowledgment of Notice

Client Name:
Date of Birth:

Minor Name (if also applicable):
Client Relationship to Minor (if also applicable):
Minor Date of Birth (if also applicable):

I hereby acknowledge that I have received and have been given an opportunity to read a copy of Co-Parenting Solutions, LLC’s Notice of Privacy Practices. I understand that if I have any questions regarding the Notice or my privacy rights, I can contact Jordana Wolfson at or 31000 Telegraph Rd., Ste 280, Bingham Farms, MI 48025.

Date Signed:

Revised 12/2019

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Document name: 5. Notice of Privacy
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July 23, 2020 2:02 pm EDT5. Notice of Privacy Uploaded by Jordana Wolfson - IP
August 18, 2020 10:10 am EDT Document owner has handed over this document to 2020-08-18 10:10:16 -