Notice of Privacy Practices

We Are Committed to Your Privacy

The privacy of your health information has always been a priority at ADO Medical, PC (“ADO”). This notice provides ADO patients and families with information about their privacy rights and ADO ongoing commitment to protecting those rights. You have the right to make choices about the way your health information is collected and used.

Questions or Concerns

ADO Medical, PC c/o Mentavi Health

Chief Privacy Officer

625 Kenmoor Ave. SE, Suite 301

Grand Rapids, MI 48546

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review this notice carefully. This notice is effective as of January 1, 2019.

If you have questions about this notice, contact ADO’s Chief Privacy Officer by sending an email to [email protected] or using the contact information listed above.

Who Will Follow This Notice

ADO Medical, PC and ADHD Online, LLC, d/b/a Mentavi Health (“Mentavi Health”)as the administrative services provider, and all medical providers affiliated with ADO will follow this Notice. 

Our Pledge Regarding Your Health Information

We understand that health information about you is personal, and we are committed to protecting it. The health information we use, create, keep and share about you may relate to physical and mental health care you receive from us. We create a record of the care and services you receive at ADO. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records related to your care, which are maintained by ADO, whether electronic or paper, and whether made by your personal doctor or support personnel. Your doctor may have different policies or notices regarding the use and disclosure of your medical information.

This notice covers the ways in which we may use and disclose health information about you. It also describes your rights and certain obligations we have regarding the use and disclosure of health information.

We are required by law to:

  • Maintain the privacy of the health information that identifies you.
  • Give you this notice of our legal duties and privacy practices with respect to health information about you.
  • Follow the terms of the version of this notice that is currently in effect.
  • Notify affected individuals following a breach of unsecured protected health information (PHI).

In many situations, we can use and share your health information without your written permission (disclosure). However, uses and disclosures that are not described here will only be made with your permission. In some situations, your written authorization is required to use or share your health information. For example, we will never sell your information or use your information for marketing purposes without your permission. The following categories describe different ways that we use and disclose health information. Not every use or disclosure in a category will be listed, but all of the ways we are permitted to use and disclose information will fall within one of the categories.

For Treatment: We may use your medical information to provide treatment or health care services to you. We may disclose health information about you to other healthcare providers who are involved in your treatment. We may consult with these providers or refer you to them as part of your care. These other providers may include but are not limited to, doctors, nurses, technicians, health care profession students, laboratory and diagnostic providers, pharmacists, nurse practitioners, physician assistants, physical therapists, or other personnel who plan your treatment or provide it to you.

Doctors and other providers who may treat you at places other than ADO need access to the most complete information possible in order to make decisions about your care. These providers are able to access your records from ADO for this purpose. Also, when these providers have referred you to ADO for treatment, they are able to access your records and your health information to follow your treatment progress. ADO has procedures and technology in place to protect the privacy and security of your records in these cases.

For Payment: We may use and disclose your medical and non-medical information so the treatment and services you receive at ADO can be billed to (and payment can be collected from) you or to help you obtain payment from your insurance company or other third parties. We may tell your health plan about medication you are going to receive to obtain prior approval or determine whether your plan will cover the medication. 

For Health Care Operations: We may share your information with Mentavi Health, which provides administrative services to our healthcare providers. Sharing information with Mentavi Health and other ADO Medical providers and affiliates helps us achieve quality improvement, population health management, and improving the overall health and wellness of the communities served by ADO. We also may use certain medical and non-medical information to contact you and ask your opinion on the quality of services you received at ADO and how we can improve our services.

We may use and disclose the minimum health information about you that is necessary or practicable for the health care operations of ADO and others who have provided care to you. These uses and disclosures are necessary to run the business operations of ADO entities and to make sure that all of our patients receive quality care. For example, we may use health information to review our treatments and services and to evaluate the performance of our staff in caring for you. We also may combine health information about many patients to decide what additional services ADO should offer, what services are not needed and whether certain new treatments are effective. We may disclose information to doctors, nurses, technicians, health care profession students and other hospital personnel for educational purposes.

Incidental Uses and Disclosures: We may use or disclose your health information when it is associated with another use or disclosure that is permitted or required by law. For example, conversations between doctors, nurses or other ADO personnel regarding your medical condition may, at times, be overheard. Please be assured that we have appropriate safeguards to avoid such situations as much as possible.

Appointment Reminders: We may use and disclose health information to remind you of an appointment you scheduled for treatment or medical service with ADO Medical providers.

Fundraising Activities: We may use certain non-medical information, including, but not limited to, your name, address, telephone number, dates and place of service, age and gender, to contact you to raise money for ADO affiliates through a foundation owned or controlled by ADO. The money raised will be used to expand and improve the services and programs we provide to the community. You have the right to opt-out of receiving fundraising communications.

Individuals Involved in Your Care or the Payment of Your Care: We may disclose health information about you to a friend or family member who is involved in your care. We also may give information to someone who is involved with payment or helps pay for your care. We may tell your family and friends about your general condition. In addition, we may disclose health information about you to an entity assisting in a disaster relief effort, so your family can be notified about your condition, status and location.

Research: Under certain circumstances, we may use and disclose health information about you for research purposes. For example, a research project may involve evaluating the health and recovery of patients who received one medication compared with those who received another for the same condition. All research projects are subject to a special approval process. This process evaluates a proposed research project and its use of health information. This process also ensures that the research needs are balanced with our patients’ needs for privacy of their health information. Before we use or disclose health information for research, the project will have been reviewed through this research approval process. We may, however, disclose health information about you to people preparing to conduct a research project. For example, we may disclose information to researchers to help them look for patients with specific medical needs, so long as the health information they review does not leave ADO. We may need to ask for your specific permission if the researcher will have access to your name, address or other personal information, or will be involved in your research-related care at ADO.

As Required by Law: We will disclose health information about you when required by federal, state or local law or regulation. For instance, we are required to report certain injuries or illnesses for public health purposes.

To Avert a Serious Threat to Health or Safety: We may use and disclose your health information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. We would only disclose your information to someone able to help prevent the threat.

Communications Regarding ADO’s Programs or Products: We may use and disclose your health information to inform you of a health-related product or service of ADO. In addition, we may use or disclose your health information to tell you about products or services related to your treatment, case management or care coordination, or to communicate alternative treatments, therapies, providers or settings of care. We may occasionally tell you about another company’s products or services but will use or disclose your health information for such communications only if they occur in person.

Health Information Exchange: ADO records and transmits health information, including prescription information, electronically. Health information is shared for the purposes outlined in this notice and is protected electronically through local, state and national health information exchanges. You can email ADO at [email protected] for more information about your rights associated with the transmission of your information through health information exchanges.

Special Situations

Organ and Tissue Donation: If you are an organ donor, we may disclose health information, as necessary, to organizations that handle organ procurement or organ, eye and tissue transplantation, or to an organ donation bank.

Military and Veterans: If you are a member of the armed forces, we may disclose medical information about you as required by military command authorities. We also may disclose health information about foreign military personnel to the appropriate foreign military authority. If a family member is in the military, in certain circumstances, we may disclose information about you to the military or an approved social services agency such as the Red Cross to advise your family member of your condition.

Workers’ Compensation: We may disclose health information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries and illnesses.

Public Health Risks: We may disclose health information about you for public health activities to:

  • Prevent or control disease, injury or disability
  • Report births and deaths and participate in disease registries
  • Report child abuse or neglect
  • Report reactions to medications or problems with products
  • Notify people of recalls for products they may be using
  • Notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition
  • Notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will make this disclosure only if you agree, or when required or authorized by law.

Health Oversight Activities: We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections and licensure. These activities are necessary for the government to monitor the health care system, government programs and compliance with civil rights laws.

Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. We also may disclose medical information about you in response to a subpoena, discovery request or other lawful processes by someone involved in the dispute, but only if you have agreed to such a release. However, your permission will not be required if the disclosure request has been signed by a judge or ordered by a court of law.

Law Enforcement: We may disclose health information if asked to do so by a law enforcement official in the following situations:

  • In response to a court order, subpoena, warrant, summons or similar process
  • To identify or locate a suspect, fugitive, material witness or missing person
  • If the information is about a victim of a crime and if, under certain limited circumstances, we are unable to obtain the person’s agreement to the disclosure
  • About a death we believe may be the result of criminal conduct
  • About criminal conduct at an ADO facility
  • In emergency circumstances, to report a crime, the location of the crime or victims, or the identity (description or location) of the person who committed the crime

Coroners, Medical Examiners and Funeral Directors: We may disclose health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We also may disclose medical information about patients to funeral directors, as necessary, to carry out their duties.

National Security and Intelligence Activities: We may disclose your health information to authorized federal officials for intelligence, counterintelligence and other national security activities authorized by law.

Protective Services for the President and Others: We may disclose health information about you to authorized federal officials so they can protect the president, authorized people or foreign heads of state, or conduct special investigations.

Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose your health information to the correctional institution or law enforcement official. This disclosure would be necessary for the institution to provide you with health care, protect your health and safety or the health and safety of others, or for the safety and security of the correctional institution.

Third Parties: We may disclose your health information to certain third parties with whom we contract to perform services on behalf of an ADO entity. If so, we will have written assurances from the third party that your information will be protected.

Highly Confidential Information: Certain health information receives special privacy protection, such as psychotherapy notes, services for mental health and developmental disabilities, alcohol and drug abuse treatment and prevention services, and certain diseases. We will use or share your highly confidential medical information only as permitted or required by law, or with your written permission.

Your Rights Regarding Your Health Information

Right to Inspect and Copy: You have the right to inspect and obtain a copy of the health information that may be used to make decisions about your care. During an in-person inspection of your information, a health professional may be in attendance to assist you. The information available to you includes medical and billing records but does not include any psychotherapy notes.

To inspect or obtain a written copy of health information that may be used to make decisions about you, you must submit a request in writing to the specific ADO facility or medical provider’s office that administered the related services. If you request a copy of the information, we may charge a fee for copying, mailing and other supplies, and any other charges incurred or associated with your request. Copies of electronic records may be provided in an electronic format that can be readily produced or in a format agreed to by you and ADO. We also will transmit such electronic information directly to an entity or person clearly and specifically designated by you.

We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to health information, you can request that the denial be reviewed. Another licensed healthcare professional chosen by ADO will review your request and the denial. The person conducting the review will not be the person who denied your initial request. We will comply with the outcome of the review.

If you are participating in research activities, we may deny your request to inspect and copy some of your health information related to that research, so long as you agreed to this access restriction in the consent form you signed before participating. We also may deny access to psychotherapy records or as otherwise permitted by law.

Right to Amend: If you feel that the health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for ADO.

Amendment requests must be made in writing and submitted to the Chief Privacy Officer. In addition, you must provide a reason that supports your request.

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. We also may deny your request if you ask us to amend information that:

  • Was not created by us, unless the person or entity that created the information is no longer available to make the amendment
  • Is not part of the health information kept by or for an ADO entity
  • Is not part of the information that you would be permitted to inspect and copy
  • Is accurate and complete

Right to an Accounting of Disclosures: You have the right to request an “accounting of disclosures,” which is a list of the disclosures we made regarding your health information, except the following types of disclosures:

  • To carry out treatment, payment or healthcare operations
  • To you or your personal representative
  • For which you have given your written permission (authorization)
  • For national security or intelligence purposes
  • To correctional institutions or to law enforcement, as described in this notice
  • As part of a limited data set (a collection of information that does not directly identify you)

For an accounting of disclosures, you must submit your request in writing to the Chief Privacy Officer. Your request must state a time period, which may not be longer than six years from the date of your request.

Your request should indicate in what form you want the list (for example, on paper or electronically). The first list you request within 12 months will be free. We may charge you for the costs of providing additional lists. We will notify you of the cost and you can choose to withdraw or modify your request at that time before any fees are incurred.

Right to Request Restrictions: You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or health care operations. We recognize that you may wish to exercise your rights differently at various ADO facilities, such as a hospital, your physician’s office or an outpatient treatment center. It is your responsibility, as the patient, to notify each individual ADO facility or provider about specific restrictions to using or disclosing your health information. You also have the right to request that we limit the health information we disclose about you to someone who is involved in your care or the payment of your care, such as a family member or friend. For example, you could ask that we not disclose information about a surgery you had to someone who would otherwise be permitted to know.

If you have paid in full for a health care item or service, and you let us know that you do not wish your health plan to receive information about that item or service, we will not share that information with your health plan, unless we are required by law to do so. If you want to make this type of restriction, you should notify the ADO facility or provider where you received the particular item or service.

For any other type of request, we are not required to agree to restrict the use or disclosure of your health information. If we do agree, we will comply with your request unless the information is needed to provide emergency treatment. If we agree to a restriction, the restriction will not apply to certain disclosures, such as those required to transfer your health care to another facility, those required by law and those required by a third-party payment contract.

To request restrictions, you must submit your request in writing to the person responsible for medical records or Chief Privacy Officer. In your request, you must tell us what information you want to limit, whether you want to limit our use, disclosure or both, and to whom you want the limits to apply. For example, you may want to limit disclosures to your spouse.

Right to Request Confidential Communications: You have the right to request that we communicate with you about healthcare matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.

To request confidential communications, you must write to the ADO Chief Privacy Officer or the provider’s office where you received the related care. Your request must specify how or where you wish to be contacted. We will not ask you the reason for your request. We will accommodate all reasonable requests.

Right to a Paper Copy of This Notice: You may ask for a copy of this notice at any time. Even if you agreed to receive this notice electronically, you still are entitled to a paper copy. You may obtain a copy of this notice on our website.

Changes to This Notice

We reserve the right to change this notice. We also reserve the right to make the revised notice effective for health information we already have about you and any information we receive in the future. We will post a copy of the current notice in the facilities, offices and locations covered by this notice. The notice will contain the effective date. In addition, each time you register at a facility or office, or you are admitted to a facility for treatment or health care services as an inpatient or outpatient, a copy of the most current notice will be made available to you.

If you believe your privacy rights have been violated, you may file a complaint with the ADO entity involved or with the secretary of the Department of Health and Human Services.

To file a complaint with ADO or any ADO facility, email [email protected] or contact:

ADO Medical c/o Mentavi Health

Chief Privacy Officer

625 Kenmoor Ave. SE, Suite 301

Grand Rapids, MI 48546


All complaints must be submitted in writing. You will not be penalized for filing a complaint.

Other Uses of Your Health Information

Other uses and disclosures of health information not covered by this notice or the laws that apply to ADO only will be made with your written permission. If you provide us with permission to use or disclose your medical information, you may revoke that permission in writing at any time. If you revoke your permission, we will not use or disclose health information about you for the reasons covered by your written authorization. We are unable to reverse any disclosures we already made with your permission, and we are required to retain our records of the care that we provided to you.