Our Pledge to You:
We understand that medical information about you and your health is personal and we are committed to protecting privacy while providing quality care. This Notice of Privacy Practices applies to all records generated by Mid Dakota Clinic, including departments, medical staff, clinics, employees and affiliated programs and services.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
We are legally required to protect the privacy of your health information. We call this information "Protected Health Information," or (PHI). It includes information that can be used to identify you that we have created or received about your past, present, or future health or condition, the provision of healthcare to you, or the payment for health care services. We must provide you with this notice about our privacy practices that explains how, when, and why we use and disclose your PHI. With some exceptions, we may not use or disclose any more of your PHI than is necessary to accomplish the purpose of the use or disclosure.
Effective Date of this Notice:
The effective date of this notice is March 15, 2009. We reserve the right to change the terms of this notice and our privacy policies. Any changes will apply to the PHI which is currently in our possession. Before we make an important change to our policies, we will promptly change this notice and post a new notice in our main reception areas. You can also request a copy of this notice from our Privacy Officer, 530-6010 or toll-free 800-472-2113 ext. 6010.
HOW WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION:
We use and disclose PHI for many different reasons. For some of these uses or disclosures, we do not need your written permission (authorization), but for others, we do.
Uses and Disclosures That Do Not Require Your Authorization: We may use and disclose your PHI without your authorization for the following reasons:
For Treatment. We may disclose your PHI to physicians, nurses, medical students, and other health care personnel who provide you with health care services or are involved in your care. For example, if you are being treated for a knee injury, we may disclose your PHI to the physical rehabilitation department in order to coordinate your care.
For Payment. We may use and disclose your PHI in order to bill and collect payment for the treatment and services provided to you. For example, we may provide portions of your PHI to our billing department and your health plan to get paid for the health care services we provided to you.
For Healthcare Operations. We may disclose your PHI in order to operate this Clinic. For example, we may use your PHI in order to evaluate the quality of healthcare services that you received or to evaluate the performance of the healthcare professionals who provided healthcare services to you. We may also provide your PHI to our accountants, attorneys, consultants, and others in order to make sure we are complying with the laws that affect us.
For Legal Proceedings or Law Enforcement. We may disclose your PHI if required by federal, state or local law, for judicial or administrative proceedings, or to assist law enforcement. For example, we make disclosures when a law requires that we report information to government agencies and law enforcement personnel about victims of abuse, neglect, or domestic violence; when dealing with gunshot or other wounds; or when ordered in a judicial or administrative proceeding.
For Public Health Activities. For example, we report information about births, deaths, and various diseases to government officials in charge of collecting that information. We may provide coroners, medical examiners, and funeral directors necessary information relating to an individual's death.
For Health Oversight Activities. For example, we will provide information to assist the government when it conducts an investigation or inspection of a healthcare provider or organization.
For Purposes of Organ Donation. We may notify organ procurement organizations to assist them in organ, eye, or tissue donation or transplants.
For Research Purposes. In certain circumstances, we may provide PHI in order to conduct medical research.
To Avoid Harm. In order to avoid a serious threat to the health or safety of a person or the public, we may provide PHI to law enforcement personnel or persons able to prevent or lessen such harm.
For Specific Government Functions. We may disclose PHI of military personnel and veterans in certain situations. And we may disclose PHI for national security purposes, such as protecting the president of the United States or conducting intelligence operations.
For Workers' Compensation Purposes. We may share your PHI as permitted or required by state law relating to workers' compensation or other similar programs.
Appointment Reminders and Health Related Benefits or Services. We may use PHI to provide appointment reminders or to give you information about treatment alternatives or other health care services or benefits we offer.
Disclosures to Family, Friends, or Others. We may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment of your healthcare if we first provide you with the opportunity to object to the disclosure and you do not object or if we infer that you do not object to the disclosure. If you are not present when we share your PHI, or you are not able to agree or disagree to our sharing your PHI because you are not capable or there is an emergency circumstance, then we may use our professional judgment to decide that sharing the PHI is in your best interest.
Uses and Disclosures That Require Your Authorization:
For any purpose other than those described above, we may use or share your PHI only when you grant us your written permission (authorization). For example, we will need an authorization from you before we send your PHI to your life insurance company.
YOUR RIGHTS REGARDING YOUR PHI:
The Right to Restrict or Limit Uses and Disclosures.
You have the right to ask us to restrict or limit the PHI we use or disclose about you for treatment, payment or healthcare operations. We will consider your request, but we are not legally required to accept it. If we accept your request, we will comply unless the information is needed to provide emergency treatment. Your request for restrictions must be made in writing and submitted to the Clinic's Privacy Officer.
The Right to Receive Confidential Communications. You have the right to ask that we send information to an alternate address (for example, sending information to your work address rather than your home address) or by alternate means (for example, by e-mail instead of regular mail). Your request must be in writing. We will try to grant your request if we feel it is reasonable.
The Right to Inspect and Copy Your PHI. In most cases, you have the right to look at or get copies of your PHI, but you must make the request in writing. If we do not have your PHI, but we know who does, we will tell you how to get it. We will respond to you within 30 days after receiving your written request. In certain situations, we may deny your request. If we do, we will tell you, in writing, what our reasons are for the denial and explain your right to have the denial reviewed. If you request copies, then we will charge you for the copies. We will also charge you for our postage costs, if you ask us to mail the copies to you. For copies of information that is not routinely copied on a standard photocopy machine, such as x-rays or photographs, we charge for the reasonable cost of the copy. If you agree to a summary or explanation of your PHI, then we will charge you a reasonable fee based on our cost of preparing the summary or explanation.
The Right to Get a List of the Disclosures We Have Made. You may ask for an accounting of certain disclosures of your PHI made by us after April 1, 2003. We will respond within 60 days of receiving your request. The list we give you will include disclosures made prior to your request and will not go back more than six years before the date of your request. The list will include the date of the disclosure, to whom PHI was disclosed (including their address, if known), a description of the information disclosed, and the reason for the disclosure. We will provide the list to you at no charge, but if you make more than one request during a 12-month period, then we will charge you a reasonable, cost-based, fee for each additional request.
The Right to Amend Your PHI. You have the right to request that we amend your PHI in our medical record files, billing records, and other records used to make decisions about your treatment and payment for your treatment. If you want to amend your records, then you must make the request in writing and provide your reason for the amendment. We will comply with your request unless we believe the information you seek to amend is correct and complete or that other circumstances apply. If we deny your request to amend information about the treatment of a mental illness or developmental disability, then you have the right to appeal our decision to a state court.
The Right to Get This Notice by E-Mail. You have the right to get a copy of this notice by e-mail. Even if you have agreed to receive this notice by e-mail, you also have the right to request a paper copy of this notice.
The Right to Revoke Your Written Permission (Authorization). You may revoke an authorization you gave previously, provided the revocation is in writing. The revocation will not apply to the extent we have already acted in reliance on the authorization.
FOR MORE INFORMATION OR TO REPORT A PROBLEM:
If you have questions and/or would like additional information regarding any rights included in this Notice of Privacy Practices, you may contact the Clinic's Privacy Officer at 530-6010 or toll-free 800-472-2113 ext. 6010. If you believe your privacy rights have been violated, you may file a complaint with the Clinic's Privacy Officer by dialing 530-6010 or toll-free 800-472-2113 ext. 6010 or writing to:
Mid Dakota Clinic
P.O. Box 5538
Bismarck, ND 58506-5538
You may also contact the United States Secretary of Health and Human Services at telephone number 877-696-6775 (toll-free), or e-mail email@example.com. or for complaints involving covered entities located in Colorado, Montana, North Dakota, South Dakota, Utah, or Wyoming: Region VIII, Office for Civil Rights, U.S. Department of Health and Human Services, 1961 Stout Street-Room 1185 FOB, Denver, CO 80294-3538. Voice Phone (303) 844-2024. FAX (303) 844-2025. TDD (303) 844-3439.
There will be no retaliation for filing a complaint.