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THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
Under the Health Insurance Portability and Accountability Act of 1996
(HIPAA), you have certain rights regarding the use and disclosure of
your protected health information. These rights are fully described
below in Alexandria Clinic, P.A.’s Notice of Privacy Practices.
Alexandria Clinic, P.A. is permitted to revise its Notice of
Privacy Practices at any time. We will provide you with a copy of the
revised Notice of Privacy Practices upon your request.
During your treatment at Alexandria Clinic, P.A., doctors,
nurses, and other caregivers may gather information about your medical
history and your current health. This notice explains how that
information may be used and shared with others. It also explains your
privacy rights regarding this kind of information. The terms of this
notice apply to health information created or received by Alexandria
Clinic, P.A. We are required by law to: make sure that medical
information that identifies you is kept private; give you this notice of
our legal duties and privacy practices with respect to medical
information about you; and follow the terms of the notice that is
currently in effect.
Your medical information may be used and disclosed for the following
purposes:
- Treatment: We may use your information to provide,
coordinate, and manage your care and treatment. For example, an
Alexandria Clinic, P.A. physician may share your medical
information with another physician for a consultation or a referral.
We will get your written consent prior to making disclosures outside
Alexandria Clinic, P.A. for treatment purposes, except in
emergency circumstances when it is not possible to get your consent.
- Payment: We may use and disclose medical information
about you so that the treatment and services you receive may be
billed to, and payment may be collected from, you, an insurance
company, or another third party. For example, we may need to give
your health plan information about treatment you received at
Alexandria Clinic, P.A. so your health plan will pay us or
reimburse you for the treatment. We may also tell your health plan
about a treatment you are going to receive to obtain prior approval
or to determine whether your plan will cover the treatment. We will
get your written consent prior to making disclosures for payment
purposes.
- Health Care Operations: We may use and disclose medical
information about you for Alexandria Clinic, P.A.’s health
care operations. Health care operations are the uses and disclosures
of information that are necessary to run Alexandria Clinic, P.A.
and to make sure that all of our patients receive quality care. For
example, we may use medical information to review our treatment and
services, and to evaluate the performance of our staff and
physicians in caring for you. We will get your written consent
before making disclosures to others outside Alexandria Clinic,
P.A. for health care operations purposes.
- Appointment Reminders and Other Health Information: We
may use your medical information to send you reminders about future
appointments. We may also contact you with information about new or
alternative treatments or other health care services. We may leave
you a message on your answering machine at your last known number,
unless you request us to do otherwise.
- To People Assisting in Your Care: Alexandria Clinic, P.A.
will only disclose medical information to those taking care of you,
helping you to pay your bills, or other close family members of
friends if these people need to know this information to help you,
and then only to the extent permitted by law. We may, for example,
provide limited medical information to allow a family member to pick
up a prescription for you. Generally, we will get your written
consent prior to making disclosures about you to family or friends.
If you are able to make your own health care decisions,
Alexandria Clinic, P.A. will ask your permission before using
your medical information for these purposes. If you are unable to
make health care decisions, Alexandria Clinic, P.A. will
disclose relevant medical information to family members or other
responsible people if we feel it is in your best interest to do so,
including in an emergency situation.
- Research: Federal law permits Alexandria Clinic, P.A.
to use and disclose medical information about you for research
purposes, either with your specific, written authorization or when
the study has been reviewed for privacy protection by an
Institutional Review Board or Privacy Board before the research
begins. In some cases, researchers may be permitted to use
information in a limited way to determine whether the study or the
potential participants are appropriate. Minnesota law generally
requires that we get your general consent before we disclose your
health information to an outside researcher. We will make a good
faith effort to obtain your consent or refusal to participate in any
research study, as required by law, prior to releasing any
identifiable information about you to outside researchers.
- As Required by Law: We will disclose medical information
about you when we are required to do so by federal, state or local
law.
- To Avert a Serious Threat to Health or Safety: We may use
and disclose medical information about you when necessary to prevent
a serious threat to your health and safety or the health and safety
of the public or another person. Any disclosure must be only to
someone able to help prevent the threat. In addition, Minnesota law
generally does not permit these disclosures unless we have your
written consent to do so or when the disclosure is specifically
required by law, including the limited circumstances in which
Alexandria Clinic, P.A. health care professionals have a “duty
to warn.”
- To Business Associates: Some services are provided by or
to Alexandria Clinic, P.A. through contracts with business
associates. Examples include Alexandria Clinic, P.A.’s
attorneys, consultants, collection agencies, and accreditation
organizations. We may disclose information about you to our business
associate so that they can perform the job we have contracted with
them to do. To protect the information that is disclosed, each
business associate is required to sign an agreement to appropriately
safeguard the information and not to redisclose the information
unless specifically permitted by law.
Your medical information may be released in the following special
situations:
- Organ and Tissue Donation: We may release your medical
information to organizations that handle organ procurement or organ,
eye or tissue transplantation, or to an organ donation bank, as
necessary to facilitate organ or tissue donation and
transplantation. The information that Alexandria Clinic, P.A.
may disclose is limited to the information necessary to make a
transplant possible.
- Military and Veterans: If you are a member of the armed
forces, we will release medical information about you as requested
by military command authorities if we are required to do so by law,
or when we have your written consent. We may also release medical
information about foreign military personnel to the appropriate
foreign military authority as required by law or with written
consent.
- Workers’ Compensation: We may release medical information
about you for workers’ compensation or similar programs. These
programs provide benefits for work-related injuries or illness. We
are permitted to disclose this information to the parties involved
in the claim without any specific consent, so long as the
information is related to a workers’ compensation claim.
- Public Health: We may disclose medical information to
public health authorities about you for public health activities.
These disclosures generally include the following:
- Preventing or controlling disease, injury or disability
- Reporting births and deaths
- Reporting child abuse or neglect, or abuse of a vulnerable
adult
- Reporting reactions to medications or problems with products
- Notifying people of recalls of products they may be using
- Notifying a person who may have been exposed to a disease or
may be at risk for contracting or spreading a disease or
condition, or
- Reporting to the FDA as permitted or required by law
- Health Oversight Activities: Alexandria Clinic, P.A. may
disclose medical information to a health oversight agency for health
oversight activities that are authorized by law. These oversight
activities include, for example, government audits, investigations,
inspections, and licensure activities. These activities are
necessary for the government to monitor the health care system,
government programs, and compliance with civil rights laws.
Minnesota law requires that patient-identifying information (for
example, your name, social security number, etc.) be removed from
most disclosures for health oversight purposes, unless you have
provided us with written consent for the disclosure.
- Lawsuits and Disputes: If you are involved in a lawsuit,
dispute, or other judicial proceeding, we will disclose medical
information about you only in response to a valid court order,
administrative order, or a grand jury subpoena, or with your written
consent.
- Law Enforcement: We may release medical
information if asked to do so by a law enforcement official in
response to a valid court order, grand jury subpoena, or warrant, or
with your written consent. In addition, we are required to report
certain types of wounds, such as gunshot wounds and some burns. In
most cases, reports will include only the fact of injury, and any
additional disclosures would require your consent or a court order.
We may also release information to law enforcement that is not a
part of the health record (in other words, non-medical
information) for the following reasons:
- To identify or locate a suspect, fugitive, material witness, or
missing person
- If you are the victim of a crime, if, under certain limited
circumstances, we are unable to obtain your agreement
- About a death we believe may be the result of criminal conduct
- About criminal conduct at our 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
will release medical information to a coroner or medical examiner in
the case of certain types of death, and we must disclose health
records upon the request of the coroner or medical examiner. This
may be necessary, for example, to identify you or determine the
cause of death. We may also release the fact of death and certain
demographic information about you to funeral directors as necessary
to carry out their duties. Other disclosures from your health record
will require the consent of a surviving spouse, parent, a person
appointed by you in writing, or your legally authorized
representative.
- National Security and Intelligence Activities: We will
release medical information about you to authorized federal
officials for intelligence, counter-intelligence, and other national
security activities only as required by law or with your written
consent.
- Protective Services for the President and Others: We will
disclose medical 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 only as required by law or with your written consent.
- Inmates: If you are an inmate of a correctional
institution or under the custody of a law enforcement official, we
will release medical information about you to the correctional
institution or law enforcement official only as required by law or
with your written consent.
You have the following rights regarding medical information we
maintain about you:
- Right to Inspect and Copy: You have the right to inspect
and receive a copy of your medical information that is used to make
decisions about your care. Usually, this includes medical and
billing records maintained by Alexandria Clinic, P.A.
If you wish to inspect and copy medical information, you must submit
your request in writing to the medical records department of the
Alexandria Clinic, P.A. If you request a copy of the
information, we may charge a fee for the costs of copying, mailing,
or other supplies associated with your request, to the extent
permitted by state and federal law.
We may deny your request to inspect and copy your information in
certain very limited circumstances. For example, we may deny access
if your physician believes it will be harmful to your health, or
could cause a threat to others. In these cases, we may supply the
information to a third party who may release the information to you.
If you are denied access to medical information, you may request
that the denial be reviewed. Another licensed health care
professional chosen by Alexandria Clinic, P.A. will review
your request and the denial. The person conducting the review will
not be the person who denied your request. We will comply with the
outcome of the review.
- Right to Request Amendment: If you believe that medical
information we have about you is incorrect or incomplete, you have
the right to ask us to change the information. You have the right to
request an amendment for as long as the information is kept by or
for Alexandria Clinic, P.A.
To request a change to your information, your request must be made
in writing and submitted to the medical records department of the
Alexandria Clinic, P.A. In addition, you must provide a reason
that supports your request.
Alexandria Clinic, P.A. 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 Alexandria Clinic, P.A., unless
the person or entity that created the information is no longer
available to make the amendment
- Is not part of the medical information kept by or for
Alexandria Clinic, P.A.
- Is not part of the information which you would be permitted
to inspect and copy, or
- Is accurate and complete
- Right to an Accounting of Disclosures: You have the right
to request an “accounting of disclosures.” This is a list of the
disclosures we made of medical information about you. This list will
not include disclosures for treatment, payment, and health
care operations; disclosures that you have authorized or that have
been made to you; disclosures for facility directories; disclosures
for national security or intelligence purposes; disclosures to
correctional institutions or law enforcement with custody of you;
disclosures that took place before April 14, 2003; and certain other
disclosures.
To request this list of disclosures, you must submit your request in
writing to the medical records department of the Alexandria
Clinic, P.A. Your request must state a time period for which you
would like the accounting. The accounting period may not go back
further than six years from the date of the request, and it may not
include dates before April 14, 2003. You may receive one free
accounting in any 12-month period. We may charge you for additional
requests.
- Right to Request Restrictions: You have the right to
request a restriction or limitation on the medical information we
use or disclose about you. For example, you could ask that we not
use or disclose information about treatment that you received to
other physicians or to your insurance company. We are not
required to agree to your request. If we do agree, we
will comply with your request unless the information is needed to
provide you emergency treatment.
To request restrictions, you must make your request in writing to
the medical records department of the Alexandria Clinic, P.A.
In your request, you must tell us:
- What information you want to limit
- Whether you want to limit our use, disclosure, or both
- To whom you want the limits to apply
- Right to Request Confidential Communications: You have
the right to request that we communicate with you about medical
matters in a certain way or at a certain location. For example, you
can ask that we contact you only at work or only by mail.
To request confidential communications, you must make your request
in writing to the Operations Manager/HIPAA Privacy Officer, your
provider, nurse or station clerk. 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, and we
may require you to provide information about how payment will be
handled.
- Right to a Paper Copy of This Notice: You have the right to
receive a paper copy of this notice. You may ask us to give you a
copy of this notice any time. This notice is also on our website at
www.alexclinic.com under
Privacy Policy listed at the bottom.
Changes to This Notice
The effective date of this notice is April 14, 2003. We reserve the
right to change this notice. We reserve the right to make the revised or
changed notice effective for medical information we already have about
you, as well as any information we receive in the future. If the terms
of this notice are changed, Alexandria Clinic, P.A. will provide
you with a revised notice upon request, and we will post the revised
notice on our website and in designated locations at Alexandria
Clinic, P.A.
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 Alexandria Clinic, P.A.,
contact Pamela Miller, Operations Manager/HIPAA Privacy Officer at (320)
763-2518 or . All complaints must be submitted in writing. You will not be
penalized for filing a complaint.
Other Uses of Medical Information
Except as described above, Alexandria Clinic, P.A. will not use
or disclose your protected health information without a specific written
authorization form from you. If you provide us with this written
authorization to use or disclose medical information about you, you may
revoke that authorization, in writing, at any time. If you revoke your
authorization, we will no longer use or disclose medical information
about you for the reasons covered by your written authorization, except
to the extent we have already relied on your authorization. We are
unable to take back any disclosures we have already made with your
permission, and we are required to retain our records of the care that
we provided to you. |
