Privacy Practices
MINNESOTA NOTICE FORM (Continued)
- Health Care Operations are activities that relate to the performance and operation of
our practice. Examples of health care operations are quality assessment and improvement
activities, business-related matters, such as audits and administrative services, and
case management and care coordination.
- Use applies only to activities within our practice
group, such as sharing, employing, applying, utilizing, examining, and analyzing
information that identifies you.
- Disclosure applies to activities outside of our
practice group, such as releasing, transferring, or providing access to information about
you to other parties.
II. Uses and Disclosures Requiring Authorization
We may use or disclose PHI for purposes outside of treatment, payment, or health care
operations when your appropriate authorization is obtained. An authorization is written permission above and beyond the general consent that permits only specific disclosures. In those instances when we are asked for information for purposes outside of treatment, payment or health care operations, we will obtain an authorization from you before releasing this information. We will also need to obtain an authorization before releasing your psychotherapy notes. Psychotherapy notes are notes we have made about our conversation during a private, group, joint, or family counseling session, which we have kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI.
You may revoke all such authorizations (of PHI or psychotherapy notes) at any time,
provided each revocation is in writing. You may not revoke an authorization to the extent
that (1) We have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right
to contest the claim under the policy.
III. Uses and Disclosures
with Neither Consent nor Authorization
We may use or disclose PHI without your consent or authorization in the following
circumstances:
- Child Abuse: If we know or have reason to believe a child is being neglected or
physically or sexually abused, or has been neglected or physically or sexually abused
within the preceding three years, we must immediately report the information to the local
welfare agency, police or sheriff's department.
- Adult and Domestic Abuse: If we have reason to believe that a vulnerable adult is
being or has been maltreated, or if we have knowledge that a vulnerable adult has
sustained a physical injury which is not reasonably explained, we must immediately report
the information to the appropriate agency in this county. We may also report the
information to a law enforcement agency.
- Vulnerable adult means a person who, regardless of residence or whether any type of service is received, possesses a physical or mental infirmity or other physical, mental, or emotional dysfunction:
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- (i) that impairs the individual's ability to provide adequately for the individual's
own care without assistance, including the provision of food, shelter, clothing, health
care, or supervision; and
- (ii) because of the dysfunction or infirmity and the need for assistance, the
individual has an impaired ability to protect the individual from maltreatment.
- Health Oversight Activities: The Minnesota Board of Psychology, Board of Social Work,
or Board of Marriage and Family Therapy may subpoena records from me if they are relevant
to an investigation it is conducting.
- Judicial and Administrative Proceedings: If you are involved in a court proceeding
and a request is made for information about the professional services that we have
provided you and/or the records thereof, such information is privileged under state law
and we must not release this information without written authorization from you or your
legally appointed representative, or a court order. This privilege does not apply when
you are being evaluated for a third party or where the evaluation is court-ordered. We
will inform you in advance if this is the case.
- Serious Threat to Health or Safety: If you communicate a specific, serious threat of
physical violence against a specific, clearly identified or identifiable potential
victim, we must make reasonable efforts to communicate this threat to the potential victim or to a law enforcement agency. We must also do so if a member of your family or someone who knows you well has reason to believe you are capable of and will carry out the
threat. We also may disclose information about you necessary to protect you from a threat
to commit suicide.
- Worker's Compensation: If you file a worker's compensation claim, your prior approval and/or a release of information is not required in order for us to release your
records to your employer, insurer, and the Department of Labor and Industry.
IV. Patient's Rights and Psychologist's Duties
Patient's Rights:
- Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of protected health information. However, we are not required to agree to a restriction you request.
- Right to Receive Confidential Communications by Alternative Means and at Alternative: You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing us. On your request, we will send your bills to another address.)
- Right to Inspect and Copy: You have the right to inspect or
obtain a copy (or both) of PHI (and psychotherapy notes) in our mental health and billing
records used to make decisions about you for as long as the PHI is maintained in the
record. We may deny your access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. On your request, we will discuss with you the details of the request and denial process.
- Right to Amend: You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. We may deny your request. On your request, we will discuss with you the details of the amendment process.
- Right to an Accounting: You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in Section III of this Notice). On your request, we will discuss with you the details of the accounting process.
- Right to a Paper Copy: You have the right to obtain a paper copy of the notice from me upon request, even if you have agreed to receive the notice electronically.
Psychologist's Duties:
- We are required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI.
- We reserve the right to change the privacy policies and practices described in this
notice. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect.
- If we revise our policies and procedures, we will notify you in writing by mail or in
person.
V. Complaints
If you are concerned that we have violated your privacy rights, or you disagree with a
decision we made about access to your records, you may further discuss this with us. If
you are not satisfied, contact Dorothee Ischler, L.P., L.M.F.T., clinic director at
507-645-9304.
You may also send a written complaint to the Secretary of the U.S. Department of
Health and Human Services or the applicable state board of your therapist. The person
listed above can provide you with the appropriate address upon request.
VI. Effective Date, Restrictions and Changes to Privacy Policy
This notice will go into effect on April 14, 2003.
We reserve the right to change the terms of this notice and to make the new notice provisions
effective for all PHI that we maintain. We will provide you with a revised notice in
writing.
