THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE
USED AND DISCLOSED, AND HOW YOU CAN GAIN ACCESS TO THIS
INFORMATION. PLEASE REVIEW IT CAREFULLY.
Protected health information (PHI), about you, is maintained as a written and/or
electronic record of your contacts or visits for healthcare services with our facility.
Specifically, PHI is information about you, including demographic information (i.e.,
name, address, phone, etc.), that may identify you and relates to your past, present
or future physical or mental health condition and related healthcare services.
Our facility is required to follow specific rules on maintaining the confidentiality of
your PHI, using your information, and disclosing or sharing this information with
other healthcare professionals involved in your care and treatment. This Notice
describes your rights to access and control your PHI. It also describes how we follow
applicable rules and use and disclose your PHI to provide your treatment, obtain
payment for services you receive, manage our healthcare operations and for other
purposes that are permitted or required by law.
Your Rights Under The Privacy Rule - Following is a statement of your rights, under
the Privacy Rule, in reference to your PHI. Please feel free to discuss any questions
with our staff.
You have the right to receive, and we are required to provide you with, a copy of this
Notice of Privacy Practices - We are required to follow the terms of this notice. We
reserve the right to change the terms of our notice, at any time. Upon your request,
we will provide you with a revised Notice of Privacy Practices if you call the facility
and request that a revised copy be sent to you in the mail or ask for one at the time
of your next visit. The Notice will also be posted in a conspicuous location within the
facility, and on our web site.
You have the right to authorize other use and disclosure - This means you have the
right to authorize any use or disclosure of PHI that is not specified within this notice.
For example, we would need your written authorization to use or disclose your PHI
for marketing purposes, for most uses or disclosures of psychotherapy notes, or if we
intended to sell your PHI. You may revoke an authorization, at any time, in writing,
except to the extent that your healthcare provider, or the facility has taken an action
in reliance on the use or disclosure indicated in the authorization.
You have the right to request an alternative means of confidential communication -
This means you have the right to ask us to contact you about medical matters using
an alternative method (i.e., email, telephone), and to a destination (i.e., cell phone
number, alternative address, etc.) designated by you. You must inform us in writing,
using a form provided by the facility, how you wish to be contacted if other than the
address/phone number that we have on file. We will follow all reasonable requests.
You have the right to inspect and copy your PHI - This means you may inspect, and
obtain a copy of your complete medical record. If your medical record is maintained
electronically, you will also have the right to request a copy in electronic format. We
have the right to charge a reasonable fee for paper or electronic copies as
established by professional, state, or federal guidelines. We may deny your request
to inspect and copy in certain very limited circumstances. If you are denied access to
medical information, you may request that the denial be reviewed.
You have the right to request a restriction of your PHI - This means you may ask us,
in writing, not to use or disclose any part of your PHI for the purposes of treatment,
payment or healthcare operations. If we agree to the requested restriction, we will
abide by it, except in emergency circumstances when the information is needed for
your treatment. In certain cases, we may deny your request for a restriction. You will
have the right to request, in writing, that we restrict communication to your health
plan regarding a specific treatment or service that you, or someone on your behalf,
has paid for in full, out-of-pocket. We are not permitted to deny this specific type of
You may have the right to request an amendment to your protected health
information - This means you may request an amendment of your PHI for as long as
we maintain this information. In certain cases, we may deny your request.
You have the right to request a disclosure accountability - This means that you may
request a listing of disclosures that we have made, of your PHI, to entities or persons
outside of the facility.
You have the right to receive a privacy breach notice - You have the right to receive
written notification if the facility discovers a breach of your unsecured PHI, and
determines through a risk assessment that notification is required. If you have
questions regarding your privacy rights, please feel free to contact our Privacy
Officer. Contact information is provided on the following page under Privacy
Who Will Follow This Notice This notice describes our facility's practices and that of:
all departments and units of the facility, medical students and other trainees
affiliated with Tristate Brain and Spine Institute, all volunteers who may assist you
while you are in the facility, and all employees, staff and other facility workers.
How We May Use or Disclose Protected Health Information - Following are examples
of uses and disclosures of your protected health information that we are permitted
to make. These examples are not meant to be exhaustive, but to describe possible
types of uses and disclosures.
• Treatment - We may use and disclose your PHI to provide, coordinate, or manage
your healthcare and any related services. This includes the coordination or
management of your healthcare with a third party that is involved in your care and
treatment. For example, we would disclose your PHI, as necessary, to a pharmacy
that would fill your prescriptions. We will also disclose PHI to other Healthcare
Providers who may be involved in your care and treatment.
• Special Notices - We may use or disclose your PHI, as necessary, to contact you to
remind you of your appointment. We may contact you by phone or other means to
provide results from exams or tests and to provide information that describes or
recommends treatment alternatives regarding your care. Also, we may contact you
to provide information for fund-raising activities. You will have the right to opt out of
such special notices, and each such notice will include instructions for opting out.
• Payment - Your PHI will be used, as needed, to obtain payment for your healthcare
services. This may include certain activities that your health insurance plan may
undertake before it approves or pays for the healthcare services we recommend for
you such as, making a determination of eligibility or coverage for insurance benefits.
• Healthcare Operations - We may use or disclose, as needed, your PHI in order to
support the business activities of our practice. This includes, but is not limited to
business planning and development, quality assessment and improvement, medical
review, legal services, auditing functions and patient safety activities.
• Health Information Organization - The facility may elect to use a health information
organization, or other such organization to facilitate the electronic exchange of
information for the purposes of treatment, payment, or healthcare operations.
• To Others Involved in Your Healthcare - Unless you object, we may disclose to a
member of your family, a relative, a close friend or any other person, that you
identify, your PHI that directly relates to that person's involvement in your
healthcare. If you are unable to agree or object to such a disclosure, we may disclose
such information as necessary if we determine that it is in your best interest based
on our professional judgment. We may use or disclose PHI to notify or assist in
notifying a family member, personal representative or any other person that is
responsible for your care, of your general condition or death. If you are not present
or able to agree or object to the use or disclosure of the PHI, then your healthcare
provider may, using professional judgment, determine whether the disclosure is in
your best interest. In this case, only the PHI that is necessary will be disclosed.
• Other Permitted and Required Uses and Disclosures - We are also permitted to use
or disclose your PHI without your written authorization for the following purposes: as
required by law; for public health activities; health oversight activities; in cases of
abuse or neglect; to comply with Food and Drug Administration requirements;
research purposes; When necessary to prevent or lessen a serious threat to the
health or safety of the individual or the public; legal proceedings; law enforcement
purposes; coroners; funeral directors; organ donation; criminal activity; military
activity; national security; worker's compensation; when an inmate in a correctional
facility; and if requested by the Department of Health and Human Services in order
to investigate or determine our compliance with the requirements of the Privacy
Rule and your confidential healthcare information may be released to other
healthcare providers in the event you need emergency care.
Our Pledge Regarding Health Information
We understand that health information about you is personal. We are committed to
protecting the privacy of your health information by following all applicable federal
and state privacy and confidentiality requirements. As a result, we have developed
policies, improved the controls over our computers and other systems which access
and store health data, and educated our employees about protecting your health
information. We are required by law to keep your health information private and to
give you this notice of our legal duties and privacy practices. When required by
Minnesota, federal or any other law, we will get your consent before using or
disclosing your health information.
You have the right to complain to us, or directly to the Secretary of the Department
of Health and Human Services if you believe your privacy rights have been violated
by us. You may file a complaint with us by notifying the Privacy Officer at: (320-763-
We will not retaliate against you for filing a complaint.
Effective Date 10/01/2014 Publication Date 10/01/2014