MMHC - Vasectomy Reversal

Privacy Practices Notice

Effective April 14, 2003

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.


THE PRIVACY OF YOUR HEALTH INFORMATION IS VERY IMPORTANT TO US.

We are required by law to:

  • Maintain the privacy of your health information;
  • Give you this Notice of our legal duties and privacy practices with respect to your health information; and
  • Follow the terms of this Notice.

This Notice will remain in effect until we revise it. We reserve the right to change our privacy practices and the terms of this Notice. Any changes we make will apply to all of the health information about you we maintain. We will make you aware of any changes by:

  • Posting the revised Notice in our office;
  • Making copies of the revised Notice available upon your request (either at our office or through the contact person listed in this Notice);
  • Posting the revised Notice on our website.

WHAT IS HEALTH INFORMATION?

Your health information is information that identifies you and relates to:

  • Your past, present or future physical or mental health or condition;
  • The treatment we provide to you; or
  • Payment for your past, present or future health care.

Your health information includes your name, address, Social Security number and other demographic information. Typically, we keep your health information in our medical record and our billing records.

USES AND DISCLOSURES OF YOUR HEALTH INFORMATION

How may we use your health information within Minnesota Men’s Health Center, P. A.?

We use your health information to make sure we can appropriately treat you, receive payment for our services and conduct our necessary business operations. Some examples are:

Treatment: Your doctor and nurses will use your health information to determine and/or order the medical care, tests, procedures and medications you may need. Other doctors and nurses in the office will need to use your health information to make sure you get appropriate care if your regular doctor is not available or has asked for help with your treatment.

Appointment reminders and other contacts: We may use your health information to contact you with reminders about your appointments, alternative treatments you may want to consider, or other of our services that may be of interest to you.

Payment: We will use your health information to check your eligibility for insurance coverage (and for what range of benefits) and prepare a bill to send to you or your insurance company.

Business operations: We may use your health information to help us train new staff, conduct quality improvement activities and perform other essential business functions.

When may we disclose your health information to persons or organizations outside of Minnesota Men’s Health Center, P.A.?

Listed below are examples of purposes for which we may disclose your health information to persons or organizations outside of Minnesota Men’s Health Center, P.A. For some of these purposes, Minnesota law requires us to obtain your written consent before disclosing your information. The list identifies those purposes. We will obtain your consent on your registration form. For the other purposes listed, no consent or authorization from you is required.

Treatment: We may disclose your health information to another health care provider related to Minnesota Men’s Health Center, P.A. involved in your treatment. For example, we may disclose your information to a related provider to order a referral, prescriptions, lab work or an X-ray for you. If the other provider is not related to Minnesota Men’s Health Center, P.A., we will ask your consent to disclose your information.

Payment: We may disclose your health information to others (such as health insurers, and third parties responsible for these costs i.e., family members) to bill and collect payment for our services. For example, in order to bill an insurance company, we may have to disclose information about when you were treated, the conditions you were treated for, and the type of treatment you received. We may disclose your health information to other health care providers and entities to assist in their billing and collection efforts. We will ask your consent to disclose your health information for billing purposes.

Business operations: We may disclose your health information to allow us to perform functions necessary for our business of health care. For example, we may disclose your information to consultants and other business associates who help us with billing, computer and transcription services. In limited situations, it may also be necessary to disclose information to allow other health care organizations to perform their business functions. For example, we may disclose your information to your insurance company to allow them to conduct quality improvement activities. We will ask your consent to disclose your health information for business operations purposes.

Persons involved in your care: We may disclose your health information to a relative (i.e., spouse, children or parents) or other person involved in your treatment or payment for your treatment, but only if you have had an opportunity to agree or object to that disclosure. For example, you may tell us directly that you do not want information disclosed to certain people, even though they may appear to be involved in your treatment or responsible for your bill. Or, you may indicate that you don’t mind us disclosing your information to a friend or family member by allowing them to join in your meeting with your doctor or asking us to contact them directly regarding test results, medical insurance benefits and scheduling details. If you are not present to agree or object, we will use our professional judgment to determine if disclosing your health information is in your best interests.

Emergencies: If you have an emergency situation, we will disclose your health information as necessary to make certain you receive the treatment you require.

Required by law: We will disclose your health information when we are required to do so by law.

Workers’ compensation: We may disclose your health information to comply with workers’ compensation and similar laws that provide benefits for work-related injuries and illnesses.

Public policy: There are several situations in which the law permits or requires us to disclose your health information for public policy purposes. These are:

  • Public health concerns: We may disclose your health information to public health authorities for certain public health activities. These include:
     
    • To prevent or control disease, injury or disability;
    • To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease;
    • To report births and deaths;
    • To report and react to potential problems with the quality, safety or effectiveness of medications or medical products;
       
  • Health oversight activities: As permitted by law, we may disclose your health information to a health oversight agency to conduct audits, investigations, inspections and other activities necessary for the government to appropriately monitor the health care system.

Special situations: There are some situations that occur rarely, but may require or permit us to disclose your health information. These include:

  • Abuse, neglect or domestic violence: We may disclose your health information to the appropriate authorities if necessary to report suspected abuse, neglect or domestic violence.
     
  • Serious threats to health or safety: We may disclose your health information when necessary to avert a serious threat to the health or safety of you, another person or the public.
     
  • Legal proceedings: If you are involved in a lawsuit or dispute, we may disclose your health information in response to a court or administrative order. We may also disclose your health information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain a court order protecting your information.
     
  • Law enforcement: We may disclose your health information for law enforcement purposes, as long as we follow specific requirements and restrictions. For example, we may disclose your information:
     
    • To comply with laws that require the reporting of gunshot wounds or other types of juries;
    • To comply with a court order or court-ordered warrant, subpoena or summons;
    • To comply with a grand jury subpoena or other appropriate administrative request;
    • To help identify or locate a suspect, fugitive, material witness or missing person;
    • In response to a request by law enforcement for information about a victim of a crime;
    • To alert law enforcement about a death that may have resulted from criminal conduct;
    • To report a crime on the premises of Minnesota Men’s Health Center, P.A.
    • In emergency circumstances, to alert law enforcement that a crime has been committed and inform them about the location of the crime or victims of the crime and the identity, description and location of the person who committed the crime.
       
  • Coroners, medical examiners and funeral directors: We may disclose your health information to a coroner or medical examiner. This may be necessary to identify a deceased person, determine a cause of death or allow them to perform their other legal duties. We may also disclose your information to funeral directors to allow them to carry out their duties.
     
  • Specialized government functions: We may disclose your health information for some specialized government functions, including:
     
    • Military and veterans activities: If you are a member of the U.S. armed forces or are a member of a foreign military service, we may release your health information as required by military authorities.
    • National security and intelligence activities: We may release your health information to authorized federal officials to conduct intelligence, counter-intelligence and other national security activities./li>
    • Protective services for the President and others: We may release your health information to authorized federal officials to provide protection for the President, foreign heads of state or other authorized individuals.
       
  • Inmates: If you are an inmate of a correctional institution or in the custody of a law enforcement official, we may disclose your health information to the institution or official as necessary to provide you with health care, protect the health and safety of you or others, and maintain the safety and security of the institution.

When may we make other disclosures of your health information?

Other uses and disclosures of your health information not covered in this Notice will be made only with your specific, written authorization. If you authorize us to use or disclose your health information, you may revoke that authorization in writing at any time.

If you revoke your authorization, we will no longer use or disclose your information for the purposes covered by your authorization. You must understand, however, that we are unable to take back any disclosures we have already made in reliance on your authorization. Please note, we are required to retain records of your care.

If you would like to authorize us to disclose your health information for any reason, please contact us at (651) 730-0775 for the appropriate form.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

You have several important rights with regard to your health information. The following explains those rights and how you may exercise them.

Right to inspect and copy: You have the right to inspect and copy your health information. We ask that you submit your request to inspect or copy in writing. If you request a copy of your health information to review your current treatment or to appeal a denial of social security disability income or benefits, the copies will be free of charge. If your request is for other purposes, we may charge you a reasonable fee. In some limited circumstances, we may deny your request to inspect or copy your information. If that happens, you may ask that the denial be reconsidered. Your request and the denial will then be reviewed by a different licensed health care professional – not the one who originally denied your request. We will comply with the decision that professional makes.

To request to inspect or copy your health information, please contact us at (651) 730-0775.

Right to request amendment: If you believe that health information we have about you is incorrect or incomplete, you may ask us in writing to amend the information. You must explain the reasons for your request. We may deny your request if the information you are asking us to change:

  • Was not created by us (unless the person that created the information is no longer available to make the amendment);
  • Is not part of the health information kept by or for us;
  • Is not part of the information you are permitted to inspect and copy; or
  • Is already accurate and complete.

If we deny your request, you have the right to file a statement of disagreement with us. Your statement will be included in any disclosures of your information we make in the future.

To request an amendment to your health information, please contact us at (651) 730-0775.

Right to request restrictions on uses and disclosures of your health information: You have the right to ask us to
limit how we use and disclose your health information for your treatment or our payment and business operations purposes. You may also ask that we not disclose your health information to family members or friends involved in your treatment or payment for your treatment. We are not required to agree to your request for a restriction. However, if we do agree, we will comply with our agreement unless there is an emergency or we are otherwise required to use or disclose the information.

To request restrictions on uses and disclosures of your health information, please contact us at (651) 730-0775.

Right to request confidential communications from us: You have the right to ask us to communicate with you about health matters in a specific way or at a specific location. For example, you may ask that we only contact you at work or by mail. We ask that you make your request for confidential communication in writing. We will comply with reasonable requests.

To request confidential communications from us, please contact us at (651) 730-0775.

Right to receive an accounting of certain disclosures of your health information we have made: You have the right to ask us to give you an accounting of certain disclosures of your health information we may have made. This accounting will not include all disclosures. For example, it will not include disclosures made:

  • For your treatment;
  • For payment of your treatment;
  • For our business operations purposes;
  • To, or authorized by, you;
  • To others involved in your care or payment for your care.

We ask that you submit your request for an accounting in writing. You may ask for up to six-years of disclosures, but the accounting will not include disclosures made before April 14, 2003. One accounting within any 12-month period will be free of charge. We may charge a reasonable fee for additional accountings, but we will notify you of the fee and allow you to withdraw or modify your request before we process it.

To request an accounting of disclosures of your health information, please contact us at (651) 730-0775.

Right to receive a copy of this Notice: You have the right to receive a paper copy of this Notice, even if you have agreed to receive it electronically.

To receive a copy of this Notice, please contact us at (651) 730-0775.

IF YOU HAVE COMPLAINTS OR QUESTIONS

If you have questions about any of the information in this Notice, please contact contact us at (651) 730-0775.

If you think your privacy rights have been violated, you may file a complaint with us by contacting (651) 730-0775.

You may also send a written complaint directly to the Department of Health and Human Services at:

Office of Civil Rights
Hubert H. Humphrey Building
200 Independence Avenue Southwest
Washington, D.C. 20201

We support your right to the privacy of your health information. We will not retaliate in any way if you file a complaint with us or with the Department of Health and Human Services.