Privacy Statement

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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.