Robbinsdale Clinic Privacy Notice
Robbinsdale Clinic, P.A.
of Privacy Practices
EFFECTIVE DATE OF THIS
NOTICE: 04 /14/2003
NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND
YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
And Legal Duty To Protect Health Information About You.
The privacy of your health information
is important to us. We are
required by federal and state laws to protect the privacy of your health
information. We refer to
this information as “protected health information,” or “PHI”.
We must give you notice of our legal duties and privacy practices
concerning PHI, including:
We must protect PHI that we have
created or received about your past, present, or future health
condition, health care we provide to you, or payment for your health
We must notify you about how we protect
PHI about you.
We must explain how, when and why we
use and/or disclose PHI about you.
We may only use and/or disclose PHI as
we have described in this Notice.
We must abide by the terms of this
We are required to abide by the terms
of this Notice. We reserve
the right to change the terms of this Notice and to make new notice
provisions effective for all PHI that we maintain.
We will post a revised notice in our offices, make copies
available to you upon request and post the revised notice on our
Minnesota Patient Consent for Disclosures
For most disclosures of your health information we are required by State of Minnesota Laws to obtain a written consent from you, unless the disclosure is authorized by Law. This consent may be obtained at the beginning of your treatment, during the first delivery of health care service, or at a later point in your care, when the need arises to disclose your health information to others outside of our organization. At times a Robbinsdale Clinic, P.A. Medical Records Staff may contact you regarding a received consent from prior to fulfilling the consents request.
Uses and Disclosures of Your Protected Health Information
and Disclosures of Your Protected Health Information for Purposes of
Treatment, Payment and Health Care Operations.
Health Care Treatment. We may use and disclose PHI about you to provide, coordinate
or manage your health care and related services.
This may include communicating with other health care providers
regarding your treatment and coordinating and managing the delivery of
health services with others. For
example, we may use and disclose PHI about you when you need a
prescription, lab work, an x-ray, or other health care services.
In addition, we may use and disclose PHI about you when referring
you to another health care provider.
Payment. We may use and disclose your medical information to others to bill and
collect payment for the treatment and services provided to you.
For example: A bill may be sent to
you or a third party payer. The information on or accompanying the bill
may include information that identifies you, as well as your diagnosis,
procedures and supplies used. Before
you receive scheduled services, we may share information about these
services with your health plan(s).
Sharing information allows us to ask for coverage under your plan
or policy and for approval of payment before we provide the services.
We may also share portions of your medical information with the
following: 1) Billing departments; 2) Collection departments or
agencies; 3) Insurance companies, health plans and their agents which
provide you coverage; 4) Utilization review personnel that review the
care you received to check that it and the costs associated with it were
appropriate for your illness or injury; and 5) Consumer reporting
agencies (e.g., credit bureaus).
Health Care Operations.
We may use and disclose PHI in performing business
activities, which we call “health care operations”. For example: Members of our staff such as the risk or quality
improvement manager, or members of the quality improvement team may use
information in your health record to assess the care and outcomes in
your case and others like it. This information will then be used in an
effort to continually improve the quality and effectiveness of the
healthcare and service we provide.
Our Business Associates. There
are some services provided in our organization through contacts with
business associates. Examples include physician services in the
Emergency Department and Radiology, and certain laboratory tests. When
these services are contracted, we may disclose your health information
to our business associate so that they can perform the job we've asked
them to do and bill you or your third party payer for services rendered.
So that your health information is protected, however, we require the
business associate to sign a contract ensuring their commitment to
protect your PHI consistent with this Notice and to appropriately
safeguard your information.
and Disclosures of Your Protected Health Information that Require Your
In addition to our use of
your health information for treatment, payment or healthcare operations,
you may give us written authorization, different from the Minnesota
Patient Consent, to use your health information or to disclose it to
anyone for any purpose. Examples of uses include but are not limited to
research, marketing, and fundraisings. If you give us an authorization,
you may revoke it in writing at any time.
Your revocation will not affect any use or disclosures permitted
by your authorization while it was in effect.
Unless you give us a written authorization, we cannot use or
disclose your health information for any reason except those described
in section E of this Notice.
and Disclosures of Your Protected Health Information that Require Your
Opportunity to Agree or Object.
In the following instances we will provide you the
opportunity to agree or object to a use or disclosure of your PHI:
Notification: We may use or disclose
information to notify or assist in notifying a family member, personal
representative, or another person responsible for your care, your
location, and general condition.
Communication with Family:
Health professionals, using their best judgment, may disclose to a
family member, other relative, close personal friend or any other person
you identify, health information relevant to that person's involvement
in your care or payment related to your care.
If you would like to object to our use or disclosure of PHI
about you in the above circumstances, please call our Privacy Officer
listed in this Notice.
And Disclosure Authorized by Law that Do Not Require Your Consent,
Authorization or Opportunity to Agree or Object.
Under certain circumstances we are
authorized to use and disclose your health information without obtaining
a consent or authorization from you or giving you the opportunity to
agree or object. These
When the use and/or disclosure is authorized or required
by law. For example,
when a disclosure is required by federal, state or local law or other
judicial or administrative proceeding.
When the use and/or disclosure is necessary for public
health activities. For
example, we may disclose PHI about you if you have been exposed to a
communicable disease or may otherwise be at risk of contracting or
spreading a disease or condition.
When the disclosure relates to victims of abuse, neglect
or domestic violence.
When the use and/or disclosure is for health oversight
example, we may disclose PHI about you to a state or federal health
oversight agency which is authorized by law to oversee our operations.
When the disclosure is for judicial and administrative
example, we may disclose PHI about you in response to an order of a
court or administrative tribunal.
When the disclosure is for law enforcement purposes.
For example, we may disclose PHI about you in order to comply
with laws that require the reporting of certain types of wounds or other
When the use and/or disclosure relates to decedents.
For example, we may disclose PHI about you to a coroner or
medical examiner, consistent with applicable laws, to carry out their
When the use and/or disclosure relates to products
regulated by the Food and Drug Administration (FDA): We may disclose
to the FDA health information relative to adverse events with respect to
food, supplements, product and product defects or post marketing
surveillance information to enable product recalls, repairs or
When the use and/or disclosure relates to cadaveric organ,
eye or tissue donation purposes.
Consistent with applicable law, we may disclose health
information to organ procurement organizations or other entities engaged
in the procurement, banking, or transplantation of organs for the
purpose of tissue donation and transplant.
When the use and/or disclosure relates to Worker’s
Compensation information: We may disclose health information
to the extent authorized by and to the extent necessary to comply with
laws relating to workers compensation or other similar programs
established by law.
When the use and/or disclosure is to avert a serious
threat to health or safety. For
example, we may disclose PHI about you to prevent or lessen a serious
and eminent threat to the health or safety of a person or the public.
When the use and/or disclosure relates to specialized
government functions. For
example, we may disclose PHI about you if it relates to military and
veterans’ activities, national security and intelligence activities,
protective services for the President, and medical suitability or
determinations of the Department of State.
When the use and/or disclosure relates to correctional
institutions and in other law enforcement custodial situations.
For example, in certain circumstances, we may disclose PHI about
you to a correctional institution having lawful custody of you.
Your Individual Rights
Right to Request Restrictions on Uses and Disclosures of PHI.
You have the right to request that we restrict the use and
disclosure of PHI about you. We
are not required to agree to your requested restrictions. However, even if we agree to your request, in certain
situations your restrictions may not be followed.
These situations include emergency treatment, disclosures to the
Secretary of the Department of Health and Human Services, and uses and
disclosures described in subsection 4 of the previous section of this
Notice. You may request a
restriction by submitting your request in writing to us.
We will notify you if we are unable to agree to your request.
Right to Request Communications via Alternative Means or to
Periodically, we will contact you by phone, email, postcard
reminders, or other means to the location identified in our records with
appointment reminders, results of tests or other health information
about you. You have the
right to request that we communicate with you through alternative means
or to alternative locations. For
example, you may request that we contact you at your work address or
phone number. While we are
not required to agree with your request, we will make efforts to
accommodate reasonable requests. You
must submit your request in writing.
Right to See and Copy PHI.
You have the right to request to see and receive a copy of
PHI contained in clinical, billing and other records used to make
decisions about you. Your
request must be in writing. Forms for these requests are located at the
receptionist’s desk and the business office.
Instead of providing you with a full copy of the PHI, we may give
you a summary or explanation of the PHI about you, if you agree in
advance to the form and cost of the summary or explanation. There are
certain situations in which we are not required to comply with your
request. Under these circumstances, we will respond to you in writing,
stating why we will not grant your request and describing any rights you
may have to request a review of our denial.
Right to Request Amendment of PHI.
You have the right to request that we make amendments to
clinical, financial and other health-related information that we
maintain and use to make decisions about you.
Your request must be in writing and must explain your reason(s)
for the amendment and, when appropriate, provide supporting
documentation. We may deny
your request if: 1) the information was not created by us (unless you
prove the creator of the information is no longer available to amend the
record); 2) the information is not part of the records used to make
decisions about you; 3) we believe the information is correct and
complete; or 4) you would not have the right to see and copy the record
as described in paragraph 3 above. We will tell you in writing the
reasons for the denial and describe your rights to give us a written
statement disagreeing with the denial. If we accept your request to
amend the information, we will make reasonable efforts to inform others
of the amendment, including persons you name who have received PHI about
you and who need the amendment.
Right to Request and Accounting of Disclosures of PHI.
You have the right to a listing of certain disclosures we have made of your PHI. You must request this in writing. You may ask for disclosures made up to six (6) years before the date of your request (not including disclosures made prior to April 14, 2003). The list will include the date of the disclosure, the name (and address, if available) of the person or organization receiving the information, a brief description of the information disclosed, and the purpose of the disclosure. If, under permitted circumstances, PHI about you has been disclosed for certain types of research projects, the list may include different types of information. If you request a list of disclosures more than once in 12 months, we can charge you a reasonable fee.
Right to Receive a Copy of This Notice.
have the right to request and receive a paper copy of this Notice at any
time. We will provide a
copy of this Notice no later than the date you first receive service
from us (except for emergency services or when the first contact is not
in person, and then we will provide the Notice to you as soon as
possible). We will make this Notice available in electronic form and
post it in our web site.
Questions or Complaints
If you want more information about our privacy practices or
have questions or concerns, please contact our Privacy Official.
If you are concerned that we may have violated your privacy
rights, or you disagree with a decision we made about access to your
health information or in response to a request you made to amend or
restrict the use or disclosure of your health information or to have us
communicate with you by alternative means or at alternative locations,
you may file a complain with our Privacy Official.
You can also submit a written complaint to the U.S. Department of
Health and Human Services. We
will provide you with the address to file your complaint with the U.S.
Department of Health and Human Services upon request.
We support your right to the privacy of your health
information. We will not
retaliate in any way if you choose to file a complaint with us or with
the U.S. Department of Health and Human Services.
Privacy Office Contact Information
Address: 3819 West Broadway, Robbinsdale, MN 55346
Telephone: 763-533-2534 Fax: 763-533-9356