NOTICE
OF PRIVACY PRACTICES
Effective:
April 14, 2003
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.
This
notice will tell you how we may use and disclose protected health information
about you. Protected health information
means any health information about you that identifies you or for which there
is a reasonable basis to believe the information can be used to identify
you. In the header above, that
information is referred to as “medical information.” In this notice, we simply call all of that
protected health information, “health information.”
This
notice also will tell you about your rights and our duties with respect to health
information about you. In addition, it
will tell you how to complain to us if you believe we have violated your
privacy rights.
Links
to Sections: Use and Disclosure
How We May Use
and Disclose Health Information About You
We
use and disclose health information about you for a number of different
purposes. Each of those purposes is described below.
·
For
Treatment
We may use health information about you to provide,
coordinate or manage the services, supports, and health care you receive from
us and other providers. We may disclose health information about you to
doctors, nurses, qualified mental retardation professionals (QMRPs),
psychologists, social workers, direct support staff and other agency staff, volunteers and other persons who are involved in supporting
you or providing care. We may consult
with other health care providers concerning you and, as part of the
consultation, share your health information with them. For example, staff may discuss your
information to develop and carry out your individual service plan. Staff may share information to coordinate
needed services, such as medical tests, transportation to a doctor’s visit,
physical therapy, etc. Staff may need to
disclose health information to entities outside of our organization (for
example, another provider or a state/local agency) to obtain new services for
you.
·
For
Payment
We may use and disclose health information about you so we
can be paid for the services we provide to you.
This can include billing a third party payor, such as Medicaid or other
state agency (for example, the state’s Office of Mental Retardation or
Developmental Disabilities), or your insurance company. For example, we may need to provide the state
Medicaid program information about the services we provide to you so we will be
reimbursed for those services. We also may need to provide the state Medicaid
program with information to ensure you are eligible for the medical assistance
program.
·
For
Health Care Operations
We may use and disclose health information about you for our
own operations. These are necessary for
us to operate Dungarvin and to maintain quality for the persons we serve. For example, we may use health information
about you to review the services we provide and the performance of our
employees supporting you. We may
disclose health information about you to train our staff and volunteers. We also may use the information to study ways
to more efficiently manage our organization, for accreditation or licensing
activities, or for our quality assurance program.
·
How
We Will Contact You
Unless you tell us otherwise in writing, we may contact you
by either telephone or by mail at either your home or your workplace. At either location, we may leave messages for
you on the answering machine or voice mail.
If you want to request that we communicate to you in a certain way or at
a certain location, see “Right to Receive Confidential Communications” on page 5
of this Notice.
·
Appointment
Reminders
We may use and disclose health information about you to
contact you to remind you of an appointment for treatment or services.
·
Treatment
and Service Alternatives
We may use and disclose health information about you to
contact you about treatment and service alternatives that may be of interest to
you.
·
Health
Related Benefits and Services
We may use and disclose health information about you to
contact you about health-related benefits and services that may be of interest
to you.
·
Marketing
Communications
We may use and disclose health information about you to
communicate with you about a product or service to encourage you to purchase
the product or service. This may be:
o
To describe a health-related product
or service that is provided by us;
o
For your treatment;
o
For case management or care
coordination for you;
o
To direct or recommend alternative treatments,
therapies, health care providers, or settings of care.
We may communicate to you about products and services in a
face-to-face communication by us to you. We also may communicate about products
or services in the form of a promotional gift of nominal value.
All other use and disclosure of health information about you
by us to make a communication about a product or service to encourage the
purchase or use of a product or service will be done only with your written
authorization.
·
Disclosures
to Family and Others
We may disclose to a parent, guardian, conservator, personal
representative, family member, other relative, a close personal friend, or any
other person identified by you, health information about you that is directly
relevant to that person’s involvement with the services and supports you
receive or payment for those services and supports. We also may use or disclose health
information about you to notify, or assist in notifying, those persons of your
location, general condition, or death.
If there is a family member, other relative, or close personal friend
that you do not want us to disclose health information about you to, please
notify or tell our staff member who is providing care to you.
·
Disaster
Relief
We may use or disclose health information about you to a
public or private entity authorized by law or by its charter to assist in
disaster relief efforts. This will be
done to coordinate with those entities in notifying a parent, guardian,
conservator, personal representative, family member, other relative, close
personal friend, or other person identified by you of your location, general
condition or death.
·
Required
by Law
We may use or disclose health information about you when we
are required to do so by law.
·
Public
Health Activities
We may disclose health information about you for public
health activities and purposes. This
includes reporting health information to a public health authority that is
authorized by law to collect or receive the information for purposes of
preventing or controlling disease. Or,
one that is authorized to receive reports of child abuse and neglect. It also includes reporting for purposes of
activities related to the quality, safety or effectiveness of a United States
Food and Drug administration regulated product or activity.
·
Victims of Abuse, Neglect or Domestic Violence
We may disclose health information about you to a government
authority authorized by law to receive reports of abuse, neglect, or domestic
violence, if we believe you are a victim of abuse, neglect, or domestic
violence. This will occur to the extent
the disclosure is: (a) required by law; (b) agreed to by you or your personal
representative; or, (c) authorized by law and we believe the disclosure is
necessary to prevent serious harm to you or to other potential victims, or, if
you are incapacitated and certain other conditions are met, a law enforcement
or other public official represents that immediate enforcement activity depends
on the disclosure.
·
Health
Oversight Activities
We may disclose health information about you to a health
oversight agency for activities authorized by law, including audits,
investigations, inspections, licensure or disciplinary actions. These and similar types of activities are
necessary for appropriate oversight of the health care system, government
benefit programs, and entities subject to various government regulations.
·
Judicial
and Administrative Proceedings
We may disclose health information about you in the course
of any judicial or administrative proceeding in response to an order of the
court or administrative tribunal. We
also may disclose health information about you in response to a subpoena,
discovery request, or other legal process but only if efforts have been made to
tell you about the request or to obtain an order protecting the information to
be disclosed.
·
Disclosures
for Law Enforcement Purposes
We may disclose health information about you to a law
enforcement official for law enforcement purposes:
a. As
required by law.
b. In
response to a court, grand jury or administrative order, warrant or subpoena.
c. To
identify or locate a suspect, fugitive, material witness or missing person.
d. About an
actual or suspected victim of a crime and that person agrees to the
disclosure. If we are unable to obtain
that person’s agreement, in limited circumstances, the information may still be
disclosed.
e. To alert
law enforcement officials to a death if we suspect the death may have resulted
from criminal conduct.
f. About
crimes that occur at our service sites.
g. To report
a crime in emergency circumstances.
·
Coroners
and Medical Examiners
We may disclose health information about you to a coroner or
medical examiner for purposes such as identifying a deceased person and
determining cause of death.
·
Funeral
Directors
We may disclose health information about you to funeral
directors as necessary for them to carry out their duties.
·
Organ,
Eye or Tissue Donation
If you have previously authorized your organ, eye or tissue
donation and transplantation, to facilitate this process we may disclose health
information about you to organ procurement organizations or other entities
engaged in the procurement, banking or transplantation of organs, eyes or tissue.
·
Research
Under certain circumstances, we may use or disclose health
information about you for research.
Before we disclose health information for research, the research will
have been approved through an approval process that evaluates the needs of the
research project with your needs for privacy of your health information. We may, however, disclose health information
about you to a person who is preparing to conduct research to permit them to
prepare for the project, but no health information will leave Dungarvin during
that person’s review of the information.
·
To
Avert Serious Threat to Health or Safety
We may use or disclose protected health information about
you if we believe the use or disclosure is necessary to prevent or lessen a
serious or imminent threat to the health or safety of a person or the
public. We also may release information
about you if we believe the disclosure is necessary for law enforcement
authorities to identify or apprehend an individual who admitted participation
in a violent crime or who is an escapee from a correctional institution or from
lawful custody.
·
National
Security and Intelligence
We may disclose health information about you to authorized
federal officials for the conduct of intelligence, counter-intelligence, and
other national security activities authorized by law.
·
Protective
Services for the President
We may disclose health information about you to authorized
federal officials so they can provide protection to the President of the United
States, certain other federal officials, or foreign heads of state.
·
Inmates;
Persons in Custody
We may disclose health information about you to a
correctional institution or law enforcement official having custody of
you. The disclosure will be made if the
disclosure is necessary: (a) to provide health care to you; (b) for the health
and safety of others; or, (c) the safety, security and good order of the
correctional institution.
·
Workers
Compensation
We may disclose health information about you to the extent
necessary to comply with workers’ compensation and similar laws that provide
benefits for work-related injuries or illness without regard to fault.
·
Other
Uses and Disclosures
Other uses and disclosures will be made only with your
written authorization. You may revoke
such an authorization at any time by notifying Karin Stockwell, Senior Director
at Dungarvin Minnesota, LLC. 1110 Centre Pointe Curve, Suite 100, Mendota Heights, MN 55120 in writing of your desire to revoke it. However, if you revoke such an authorization,
it will not have any affect on actions taken by us in reliance on it.
Your Rights With
Respect to Health Information About You
You
have the following rights with respect to health information that we maintain
about you:
·
Right
to Request Restrictions
You have the right to request that we restrict the uses or
disclosures of health information about you to carry out treatment, payment, or
health care operations. You also have
the right to request that we restrict the uses or disclosures we make to: (a) a
family member, other relative, a close personal friend or any other person
identified by you; or, (b) for to public or private entities for disaster relief
efforts. For example, you could ask that
we not disclose health information about you to your brother or sister.
To request a restriction, you may do so at any time. If you
request a restriction, you should do so to Karin Stockwell, Senior Director at
Dungarvin Minnesota, LLC. 1110 Centre
Pointe Curve, Suite 100, Mendota Heights, MN 55120, telephone number (651) 699-6050 and
tell us: (a) what information you want to limit; (b) whether you want to limit
use or disclosure or both; and, (c) to whom you want the limits to apply (for
example, disclosures to your brother or sister).
We are not
required to agree to any requested restriction. However, if we do
agree, we will follow that restriction unless the information is needed to
provide emergency treatment. Even if we
agree to a restriction, either you or we can later terminate the restriction.
·
Right
to Receive Confidential Communications
You have the right to request that we communicate health
information about you to you in a certain way or at a certain location. For
example, you can ask that we only contact you by mail or at work. We will not require you to tell us why you
are asking for the confidential communication.
If you want to request confidential communication, you must
do so in writing to Karin Stockwell, Senior Director at Dungarvin Minnesota, LLC.
1110 Centre Pointe
Curve, Suite 100, Mendota Heights, MN 55120.
Your request must state how or where you can be contacted.
We will accommodate your request. However, we may, if necessary, require
information from you concerning how payment will be handled. We also may require an alternate address or
other method to contact you.
·
Right
to Inspect and Copy
With a few very limited exceptions, such as psychotherapy
notes, you have the right to inspect and obtain a copy of health information
about you.
To inspect or copy health information about you, you must
submit your request in writing to Karin Stockwell, Senior Director at Dungarvin
Minnesota, LLC. 1110
Centre Pointe Curve, Suite 100, Mendota Heights, MN 55120. Your request should state
specifically what health information you want to inspect or copy. If you request a copy of the information, we
may charge a fee for the costs of copying and, if you ask that it be mailed to
you, the cost of mailing.
We will act on your request within thirty (30) calendar days
after we receive your request. If we
grant your request, in whole or in part, we will inform you of our acceptance
of your request and provide access and copying.
We may deny your request to inspect and copy health
information if the health information involved is:
a. Psychotherapy
notes;
b. Information
compiled in anticipation of, or use in, a civil, criminal or administrative
action or proceeding.
If we deny your request, we will inform you of the basis for
the denial, how you may have our denial reviewed, and how you may
complain. If you request a review of our
denial, it will be conducted by a licensed health care professional designed by
us who was not directly involved in the denial.
We will comply with the outcome of that review.
·
Right
to Amend
You have the right to ask us to amend health information
about you. You have this right for so
long as the health information is maintained by us.
To request an amendment, you must submit your request in
writing to Karin Stockwell, Senior Director at Dungarvin Minnesota, LLC. 1110 Centre Pointe Curve,
Suite 100, Mendota Heights, MN 55120.
Your request must state the amendment desired and provide a reason in support
of that amendment.
We will act on your request within sixty (60) calendar days
after we receive your request. If we
grant your request, in whole or in part, we will inform you of our acceptance
of your request and provide access and copying.
If we grant the request, in whole or
in part, we will seek your identification of and agreement to share the
amendment with relevant other persons. We also will make the appropriate amendment
to the health information by appending or otherwise providing a link to the
amendment.
We may deny your request to amend health information about
you. We may deny your request if it is
not in writing and does not provide a reason in support of the amendment. In addition, we may deny your request to
amend health information if we determine that the information:
a. Was not
created by us, unless the person or entity that created the information is no
longer available to act on the requested amendment;
b. Is not
part of the health information maintained by us;
c. Would not
be available for you to inspect or copy; or,
d. Is
accurate and complete.
If we deny your request, we will inform you of the basis for
the denial. You will have the right to
submit a statement of disagreeing with our denial. We may prepare a rebuttal to that
statement. Your request for amendment,
our denial of the request, your statement of disagreement, if any, and our
rebuttal, if any, will then be appended to the health information involved or
otherwise linked to it. All of that will
then be included with any subsequent disclosure of the information, or, at our
election, we may include a summary of any of that information.
If you do not submit a statement of disagreement, you may
ask that we include your request for amendment and our denial with any future
disclosures of the information. We will include your request for amendment and
our denial (or a summary of that information) with any subsequent disclosure of
the health information involved.
You also will have the right to
complain about our denial of your request.
·
Right
to an Accounting of Disclosures
You have the right to receive an accounting of disclosures
of health information about you. The
accounting may be for up to six (6) years prior to the date on which you request
the accounting but not before April 14, 2003.
Certain
types of disclosures are not included in such an accounting:
a. Disclosures
to carry out treatment, payment and health care operations;
b. Disclosures
of your health information made to you;
c. Disclosures
that are incident to another use or disclosure;
d. Disclosures
that you have authorized;
e. Disclosures
for disaster relief purposes;
f. Disclosures
for national security or intelligence purposes;
g. Disclosures
to correctional institutions or law enforcement officials;
h. Disclosures
that are part of a limited data set for purposes of research, public health, or
health care operations (a limited data set is where things that would directly
identify you have been removed.
i. Disclosures
made prior to April 14, 2003.
Under certain circumstances your right to an accounting of
disclosures to a law enforcement official or a health oversight agency may be
suspended. Should you request an accounting during the period of time your
right is suspended, the accounting would not include the disclosure or
disclosures to a law enforcement official or to a health oversight agency.
To request an accounting of disclosures, you must submit
your request in writing to Karin Stockwell, Senior Director at Dungarvin
Minnesota, LLC. 1110
Centre Pointe Curve, Suite 100, Mendota Heights, MN 55120. Your request must state a time
period for the disclosures. It may not
be longer than six (6) years from the date we receive your request and my not
include dates before April 14, 2003.
Usually, we will act on your request within sixty (60)
calendar days after we receive your request.
Within that time, we will either provide the accounting of disclosures
to you or give you a written statement of when we will provide the accounting
and why the delay is necessary.
There is no charge for the first accounting we provide to
you in any twelve (12) month period. For
additional accountings, we may charge you for the cost of providing the
list. If there will be a charge, we will
notify you of the cost involved and give you an opportunity to withdraw or
modify your request to avoid or reduce the fee.
·
Right
to Copy of this Notice
You have the right to obtain a paper copy of our Notice of
Privacy Practices. You may obtain a
paper copy even though you agreed to receive the notice electronically. You may request a copy of our Notice of
Privacy Practices at any time.
You may obtain a copy of our Notice of Privacy Practices
over the Internet at our web site, www.dungarvin.com.
To obtain a paper copy of this notice, contact to Karin Stockwell,
Senior Director at Dungarvin Minnesota, LLC. 1110 Centre Pointe Curve,
Suite 100, Mendota Heights, MN 55120,
telephone number (651) 699-6050.
·
Generally
We are required by law to maintain the privacy of health
information about you and to provide individuals with notice of our legal
duties and privacy practices with respect to health information.
We are required to abide by the terms of our Notice of
Privacy Practices in effect at the time.
·
Our
Right to Change Notice of Privacy Practices
We reserve the right to change this Notice of Privacy
Practices. We reserve the right to make the new notice’s provisions effective
for all health information that we maintain, including that created or received
by us prior to the effective date of the new notice.
·
Availability
of Notice of Privacy Practices
A copy of our current Notice of Privacy Practices will be
posted at the Dungarvin office(s). A
copy of the current notice also will be posted on our web site, www.dungarvin.com.
At any time, you may obtain a copy of the current Notice of
Privacy Practices by Karin Stockwell, Senior Director at Dungarvin Minnesota, LLC.
1110 Centre Pointe
Curve, Suite 100, Mendota Heights, MN 55120,
telephone number (651) 699-6050.
·
Effective
Date of Notice
The
effective date of the notice will be stated on the first page of the notice.
·
Complaints
You may complain to us and to the United States Secretary of
Health and Human Services if you believe your privacy rights have been violated
by us.
To file a complaint with us, contact Karin Stockwell, Senior
Director at Dungarvin Minnesota, LLC. 1110 Centre Pointe Curve, Suite 100, Mendota Heights, MN 55120, telephone number (651) 699-6050. All complaints should be submitted in
writing.
To file a complaint with the United States Secretary of
Health and Human Services, send your complaint to him or her in care of: Office
for Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue SW, Washington, D.C. 20201.
You will not be retaliated against for filing a complaint.
·
Questions
and Information
If you have any questions or want more information
concerning this Notice of Privacy Practices, please contact Karin Stockwell, Senior Director at
Dungarvin Minnesota, LLC. 1110 Centre Pointe Curve, Suite 100, Mendota Heights, MN 55120, telephone number (651) 699-6050.