NOTICE OF PRIVACY PRACTICES
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.
During your treatment, our caregivers may gather information about your medical history and current health. This notice explains how that information may be used and shared. It also explains your privacy rights. This Notice applies to health information created or received by Proof Alliance. 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, a Proof Alliance 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 Proof Alliance 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 Proof Alliance 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 Proof Alliance’s health care operations. Health care operations are the uses and disclosures of information that are necessary to run Proof Alliance. For example, we may use medical information to review our treatment and services, and to evaluate the performance of our staff. We will get your written consent before making disclosures to others outside Proof Alliance for health care operations purposes.
- Appointment Reminders and Other Health Information: We may use your medical information to send you reminders about future appointments, or to contact you with information about new or alternative treatments or other health care services.
- Fund-Raising: Occasionally, Proof Alliance may use limited information (your name, address, and the dates of services) to let you know about fund-raising or other charitable events.
- Facility Directory: We may include certain limited information about you (such as your name) in our directory while you are a patient. This information may be released to people who ask for you by name so your family or friends can know your location. If you would prefer that Proof Alliance not make these disclosures, your request must be made in writing and submitted to email@example.com.
- To People Assisting in Your Care. Proof Alliance 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. If you are able to make your own health care decisions, Proof Alliance will ask your permission before using your medical information for these purposes. If you are unable to make health care decisions, Proof Alliance 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 Proof Alliance 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. 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 to participate in any research study, as required by law, prior to releasing 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 health and safety. Any disclosure must be only to someone able to help prevent the threat, and only when the disclosure is specifically required by law, including the limited circumstances in which Proof Alliance health care professionals have a “duty to warn.”
- To Business Associates: Some services are provided by or to Proof Alliance through contracts with business associates. We may disclose information about you to our business associate so that they can perform the job we have contracted with them to do. Each business associate is required to sign an agreement to safeguard the information.
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 transplantation to facilitate donation and transplantation.
- Military and Veterans: We will release medical information about you as requested by military command authorities if we are required to do so by law
- Workers’ Compensation: We may release medical information about you for workers’ compensation or similar programs.
- 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: Proof Alliance may disclose medical information to a health oversight agency for oversight activities that are authorized by law, such as government investigations necessary to monitor the health care system. Patient-identifying information (for example, your name) will be removed from most disclosures for these purposes.
- Lawsuits and Disputes: If you are involved in a lawsuit, dispute, or other judicial proceeding, we will disclose medical information about you in response to a valid court order, administrative order, or a grand jury subpoena.
- 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. 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. 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; and 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. We may also release the fact of death and certain demographic information about you to funeral directors as necessary to carry out their duties.
- 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.
- 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, or other persons, or to conduct special investigations if required by law.
- 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.
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. If you wish to inspect and copy medical information, please contact the Clinic Coordinator at 651-917-2370. We may charge a fee for the costs of copying, mailing, or other supplies associated with your request. If we maintain your health information in an electronic health record, you have the right to receive a copy of your health information in electronic form. You may direct us to provide such electronic health information directly to an entity or person you specify in writing. We may deny your request to inspect and copy your information in very limited circumstances. For example, we may deny access if your physician believes it will be harmful to you or 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 Proof Alliance 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 Proof Alliance.
To request a change to your information, your request must be made in writing and submitted to firstname.lastname@example.org. In addition, you must provide a reason that supports your request. Proof Alliance 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 Proof Alliance, 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 Proof Alliance; 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 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; and certain other disclosures. To request this list of disclosures, you must submit your request in writing to email@example.com. Your request must state a time period for which you would like the accounting, which may not go back further than six years from the date of the request. 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. If you pay out-of-pocket in full for an item or service, then you may request that we not disclose information pertaining solely to such item or service to your health plan for purposes of payment or health care operations. We are required to agree with such a request. However, we are not required to agree to any other 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 firstname.lastname@example.org. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure, or both; and (3) to whom you want the limits to apply, for example, if you want to prohibit disclosures to your spouse.
- 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 only contact you only at work or only by mail. To request confidential communications, you must make your request in writing to email@example.com. 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.
Changes to This Notice
The effective date of this notice is November 15, 2013. We may change this notice and 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 changed, we will provide you with a revised notice upon request.
Complaints or Questions
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 Proof Alliance, or to ask a question about this Notice, contact the Proof Alliance Privacy Officer at 651.917.2370. 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, Proof Alliance will not use or disclose your protected health information without a written authorization from you. If you provide us with this written authorization, 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.
rev. Sept. 2015