Privacy Statement
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the HIPPA Notice of Privacy Practices (31K)
HIPAA NOTICE OF PRIVACY PRACTICES
Midwest Health Center for Women
Effective April 15, 2003
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT
YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS
TO THIS INFORMATION
PLEASE REVIEW IT CAREFULLY!!!!
If you have any questions about this notice, please
contact Midwest Health Center for Women at 612-332-2311.
WHO WILL FOLLOW THIS NOTICE:
- Midwest Health Center for Women
This notice describes our privacy practices.
OUR PLEDGE REGARDING HEALTH INFORMATION:
We understand that health information about you and
your health care is personal. We are committed to protecting
health information about you. We create a record of
the care and services you receive from us. 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 of your care generated by this
health care practice, whether made by your personal
doctor or others working in this office. This notice
will tell you about the ways in which we may use and
disclose health information about you. We also describe
your rights to the health information we keep about
you, and describe certain obligations we have regarding
the use and disclosure of your health information.
We are required by law to:
- give you this notice of our legal duties and privacy
practices with respect to health information about
you;
- follow the terms of the notice that is currently
in effect and
- make sure that health information that identifies
you is kept private.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT
YOU.
The following categories describe different ways that
we use and disclose health information. For each category
of uses or disclosures we will explain what we mean
and try to give some examples. Not every use or disclosure
in a category will be listed. However, all of the ways
we are permitted to use and disclose information will
fall within one of the categories.
For Treatment: We may disclose your records without
a signed and dated consent under the following circumstances:
1) for a medical emergency when the provider is unable
to obtain the patient's consent due to the patient's
condition or the nature of the medical emergency; or
2) to other providers within related health care entities
when necessary for the current treatment of the patient.
In all other circumstances, we will require a signed
and dated authorization form from you.
For Payment: We will only disclose and release your
personal health information in your medical record if
we have a signed and dated consent from you or your
legally authorized representative, except when the release
is specifically authorized by law. These exceptions
are noted in the following statements. Please note also
that if you choose not to authorize release of records
to your insurance company, we will need to require that
you prepay for your services, and then be reimbursed
once your insurance company pays.
For Health Care Operations: We may use and disclose
health information about you for operations of our health
care practice. These uses and disclosures are necessary
to run our practice and make sure that all of our patients
receive quality care. For example, we may use health
information to review our treatment and services and
to evaluate the performance of our staff in caring for
you. We may also combine health information about many
patients to decide what additional services we should
offer, what services are not needed, whether certain
new treatments are effective, or to compare how we are
doing with others and to see where we can make improvements.
We may remove information that identifies you from this
set of health information so others may use it to study
health care delivery without learning who our specific
patients are. Please be aware that at no time will we
use any of your information either anonymously or in
any other way for marketing purposes without first requesting
your specific written authorization.
Fundraising Activities: As we are a not-for-profit
clinic, we may disclose health information about you
in an effort to raise money. However, we will only do
so without disclosing your name, and then only if you
have signed an authorization form allowing us to do
so specifically for the purpose of fundraising and grant
proposals.
As Required By Law: We will disclose health information
about you when required to do so by federal, state or
local law.
To Avert a Serious Threat to Health or Safety: We may
use and disclose health information about you only in
the case of a medical emergency when we are unable to
obtain your consent due to your condition or the nature
of the medical emergency.
Military and Veterans: If you are a member of the armed
forces or separated/discharged from military services,
we may release health information about you as required
by military command authorities or the Department of
Veterans Affairs as may be applicable under state law.
We may also release health information about fore4ing
military personnel to the appropriate foreign military
authorities under the same guidelines.
Workers' Compensation: We may release health information
about you for workers' compensation or similar programs.
These programs provide benefits for work-related injuries
or illness.
Public Health Risks: We may disclose health information
about you for public health activities. These activities
may include the following:
- to prevent or control disease, injury or disability;
- to report births and deaths;
- to report child abuse or neglect;
- to report reactions to medications or problems with
products;
- to notify people of recalls of products they may
be using;
- to notify organizations required to receive information
on FDA-regulated products;
- to notify a person who may have been exposed to
a disease or may be at risk for contracting or spreading
a disease or condition;
- to notify the appropriate government authority if
we believe a patient has been the victim of abuse,
neglect or domestic violence. We will only make this
disclosure if you agree or when required or authorized
by Minnesota state law.
Any information we disclose on the basis of the preceding
conditions will be disclosed in such a way as dictated
by Minnesota state regulations.
Health Oversight Activities: We may disclose health
information to a health oversight agency for activities
authorized by state law. Specifically we must release
your information to the commissioner of health or the
health data institute, and will use patient identifiers
that are encrypted, should they be done so in any computerized
format.
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 order or administrative order;
however we will require that the party requesting the
information obtain an authorization to release this
information that must be signed by you or your personal
representative.
Law Enforcement: We may release health information
if asked to do so by a law enforcement official:
- in reporting certain injuries, as required by law,
gunshot wounds, burns, injuries to perpetrators of
crime;
- in response to a court order, subpoena, warrant,
summons or similar process;
- to identify or locate a suspect, fugitive, material
witness, or missing person;
- name and address;
- date of birth or place of birth;
- social security number;
- blood type or Rh factor;
- type of injury;
- date and time of treatment and/or death, if applicable;
and
- a description of distinguishing physical characteristics.
- about the victim of a crime, if the victim agrees
to disclosure or under certain limited circumstances,
we are unable to obtain the person's agreement;
- about a death we believe may be the result of criminal
conduct;
- about criminal conduct at our facility;
- in an 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, Health Examiners and Funeral Directors: We
may release health information to a coroner or health
examiner. This may be necessary, for example, to identify
a deceased person or determine the cause of death. We
may also release health information about patients to
funeral directors as necessary to carry out their duties.
National Security and Intelligence Activities: We may
release health information about you 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 may provide protection to
the President, other authorized persons 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 release health information about you to the correctional
institution or law enforcement official. This release
would be necessary (1) for the institution to provide
you with health care; (2) to protect your health and
safety or the health and safety of others; or (3) for
the safety and security of the correctional institution.
YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU
You have the following rights regarding health information
we maintain about you:
Right to Inspect and Copy: You have the right to inspect
and copy health information that may be used to make
decisions about your care. Usually, this includes health
and billing records.
To inspect and copy health information that may be
used to make decisions about you, we will require that
you fill out our official authorization release form,
sign and date it and return it to the attention of Privacy
Officer. You may request this form by telephone, fax,
mail or email or in person. There may or may not be
a charge, depending upon the number of copies requested.
The first request will be fulfilled at no charge for
this information; however after the first request, we
may or may not charge you the allowed amount under state
regulations. This information will be disclosed to you
at the time that you make your request, and prepayment
would be required should there be a charge applicable.
We may deny your request to inspect and copy in certain
very limited circumstances. If you are denied access
to health information, you may request that the denial
be reviewed. Another licensed health care professional
chosen by our practice will review your request and
the denial. The person conducting the review will not
be the person who denied your original request. We will
comply with the outcome of this review.
Right to Amend: If you feel that 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 we keep the information.
To request an amendment, we will require that you fill
out our official authorization release form, sign and
date it and return it to the attention of Privacy Officer.
You may request this form by telephone, fax, mail or
email. In addition, you must provide a reason that supports
your request for an amendment.
We may deny your request for an amendment if it is
not in writing or does not include a reason to support
the request. In addition, we 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 our practice;
- is not part of the information which you would be
permitted to inspect and copy; or
- is accurate and complete.
Any amendment we make to your health information will
be disclosed to those with whom we disclose information
as previously specified.
Right to an Account of Disclosures: You have the right
to request a list accounting for any disclosures of
your health information we have made, except for uses
and disclosures for treatment, payment, and health care
operations, as previously described.
To request this list of disclosures, you must submit
your request in writing to the Privacy Officer. Your
request must state a time period which may not be longer
than six years and may not include dates before April
15, 2003. The first list you request within a 12-month
period will be free. For additional lists, we may or
may not charge you for the costs of providing the list.
We will notify you of any cost involved and you may
choose to withdraw or modify your request at that time
before any costs are incurred. We will mail you a list
of disclosures in paper form within 30 days for your
request, or notify you if we are unable to supply the
list within that time period and by what date we can
supple the list; but this date will not exceed a total
of 60 days from the date you made the request.
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. You also have the right to
request a limit on the health information we disclose
about you to someone who is involved in your care or
the payment for your care, such as a family member or
friend. For example, you could ask that we restrict
a specified nurse from use of your information, or that
we not disclose information to your spouse about a surgery
you had.
We are not required to agree to your request for restrictions
if it is not feasible for us to ensure our compliance
with HIPAA or Minnesota state regulations or believe
it will negatively impact the care we may provide you.
If you do not agree, we will comply with your request
unless the information is needed to provide you emergency
treatment. To request a restriction, we will require
that you fill out our official restrictions request
form, sign and date it and return it to the attention
of Privacy Officer. You may request this form by telephone,
fax, mail, email or in person.
Right to Request Confidential Communications: You have
the right to request that we communicate with you about
health 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 a post office box.
To request confidential communications, you must make
your request in writing to the Privacy Officer. We will
not ask you the reason for your request. We will accommodate
all reasonable requests. Your request must specify how
or where you wish to be contacted.
Right to a Paper Copy of This Notice: You have the
right to obtain a paper copy of this notice at any time.
However, at the time of first service rendered after
April 14, 2003, it is required that you receive a paper
copy. To obtain a copy, please request it from thePrivacy
Officer.
You may also obtain a copy of this notice by requesting
a copy of this notice be sent through electronic mail
to finance.mhcw@visi.com.
If we know that the electronic message has failed to
be delivered, a paper copy of the notice will be provided.
Even if you have received a notice electronically, you
still retain the right to receive a paper copy upon
request.
If the first service delivery is delivered electronically,
other than by telephone, we provide electronic notice
in the same medium, automatically and contemporaneously
in response to a first request for service.
CHANGES TO THIS NOTICE
We reserve the right to change this notice. We reserve
the right to make the revised or changed notice effective
for health information we already have about you as
well as any information we receive in the future. We
will post a copy of the current notice in our facility.
The notice will contain on the first page, in the top
left-handed corner, the effective date. In addition,
each time you register for treatment or health care
services, we will offer you a copy of the current notice
in effect.
COMPLAINTS
If you believe your privacy rights have been violated,
you may file a complaint with us or with the Secretary
of the Department of Health and Human Services. To file
a complaint with us, contact the Privacy Officer. 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 permission. If you
provide us permission to use or disclose health information
about you, you may revoke that permission, in writing,
at any time. If you revoke your permission, 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 permission, and that
we are required to retain our records of care that we
provided to you.
Acknowledgement of Receipt of this Notice
We will request that you sign a separate form or notice
acknowledging you have received a copy of this notice.
If you choose, or are not able to sign, a staff member
will sign their name and date in acknowledgement for
you. This acknowledgement will be filed with your medical
records. |
