MINNESOTA NOTICE OF PRIVACY PRACTICES

FOR THE OFFICE OF:
Smile Designers
1511 Carlson St Marshall MN 507-532-3353
Contact person: DeeAnn DePestel

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.

YOUR RIGHTS

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

COPY OF MEDICAL RECORDS

Receive an electronic or paper copy of your medical record

  • You can ask to see or copy an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
  • We will provide a copy or a summary of your health information within a reasonable time.
  • If you ask to see or receive a copy of your record for purposes of reviewing current medical care, we may not charge you a fee. [Minn. Stat. § 144.292 subd. 6]
  • If you request copies of your patient records of past medical care, or for certain appeals, we may charge you specified fees. [Minn. Stat. § 144.292 subd. 6]

Request to amend medical records

Ask us to correct your medical record

  • You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
  • We may say “no” to your request, but we’ll tell you why in writing within 60 days

Request Confidential Communicaiton

Request for us to contact you confidentially

  • You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
  • We will say “yes” to all reasonable requests

Request to Limit Use/Sharing of TPO

Ask us to limit what we use or share

  • You can ask us not to use or share certain health information for treatment, payment, or our operations (TPO). We are not required to agree to your request, and we may say “no” if it would affect your care.
  • If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information. Minnesota Law requires consent for disclosure of treatment, payment, or operations information. [Minn. Stat. § 144.293 subd. 2

List of those with Whome We've Shared Information

Get a list of those with whom we’ve shared information

  • You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
  • We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, costbased fee if you ask for another one within 12 months.

Copy of this Privacy Notice

Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice
electronically. We will provide you with a paper copy promptly.

File a Complaint

File a complaint if you feel your rights are violated

  • You can complain if you feel we have violated your rights by contacting us using the information above.
  • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting this link.
  • We will not retaliate against you for filing a complaint.

YOUR CHOICES

Request Us Not To Share

For certain health information, you can tell us your choices about what we share.

If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us NOT to:

  • Share information with your family, close friends, or others involved in your care
  • Share information in a disaster relief situation
  • Include your information in a hospital directory

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

Will Never Share Without Permission

In these cases we will never share your information unless you give us written permission:

  • Marketing purposes
  • Sale of your information
  • Most sharing of psychotherapy notes

Minnesota Law also requires consent for most other sharing purposes

Fundraising

In the case of fundraising:

  • We may contact you for fundraising efforts, but you can tell us not to contact you again.

Uses and Disclosure for TPO

How do we typically use or share your health information?

We typically use or share your health information in the following ways. We need your consent before we disclose protected health information for treatment, payment, and operations purposes, unless the disclosure is to a related entity, or the disclosure is for a medical emergency and we are unable to obtain your consent due to your condition or the nature of the medical emergency. [Minn. Stat. § 144.293, subd. 2 and 5]

Treat You

We can use your health information and share it with other professionals who are treating you only if we have your consent. We can only release your health records to health care facilities and providers outside our network without your consent if it is an emergency and you are unable to provide consent due to the nature of the emergency. We may also share your health information with a provider in our network. [Minn. Stat. § 144.293, subd. 2 and 5]
Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization

We can use and share your health information to run our practice, improve your care, and contact you when necessary. We are required to obtain your consent before we release your health records to other providers for their own health care operations. [Minn. Stat. § 144.293, subd. 2 and 5]
Example: We use health information about you to manage your treatment and services.

Bill for your services

We can use and share your health information to bill and get payment from health plans or other entities only if we obtain your consent. [Minn. Stat. § 144.293, subd. 2 and 5]
Example: We give information about you to your health insurance plan so it will pay for your services.

Other Uses and Disclosures

How else can we use or share your health information?

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html

Public Heath and Safety

Help with public health and safety issues

We can share health information about you for certain situations such as:

  • Preventing disease
  • Helping with product recalls
  • Reporting adverse reactions to medications
  • Reporting suspected abuse, neglect, or domestic violence
  • Preventing or reducing a serious threat to anyone’s health or safety

Research

Do research

We can use or share your information for health research if you do not object.
[Minn. Stat. § 144.295 subd. 1]

Comply with the Law

Comply with the law

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law. [Minn. Stat. §144.293 subd. 2]

Organ and Tissue Donation

Respond to organ and tissue donation requests

We can share health information about you with organ procurement organizations only with your consent. [Minn. Stat. § 525A.14]

Medical Examiner

Work with a medical examiner or coroner

We can share health information with a coroner and medical examiner when an individual dies. We need consent to share information with a funeral director. [Minn. Stat. § 390.11 subd. 7 (a)]

WORKERS’ COMP, LAW ENFORCEMENT GOVERNMENT

Address workers’ compensation, law enforcement, and other government requests

We can use or share health information about you:

  • For workers’ compensation claims
  • For law enforcement purposes or with a law enforcement official with your consent, unless required by law. [Minn. Stat. § 144.293, subd. 2]
  • With health oversight agencies for activities authorized by law
  • For special government functions such as military, national security, and presidential protective services with your consent, unless required by law. [Minn. Stat. § 144.293, subd. 2]

RESPOND TO LEGAL ACTIONS

Respond to lawsuits and legal actions

We can share health information about you in response to a court or administrative order, or in response to a subpoena. (NOTE TO PROVIDER: Minnesota may require a court order; however, providers should consult with legal counsel upon receipt of these types of documents.) [Minn. Stat. § 144.293 subd. 2]

OTHER STATE LAW

Other State Law

The Privacy Rule requires you to describe any state or other laws that require greater limits on disclosures. For example, “We will never share any substance abuse treatment records without your written permission.” Insert this type of information here. If no laws with greater limits apply to your entity, no information needs to be added.

(“In Minnesota, we need your consent before we disclose protected health information for treatment, payment, and operations purposes, unless the disclosure is to a related entity, or the disclosure is for a medical emergency and we are unable to obtain your consent.”) [Minn. Stat. §§ 13.386, 254A.09]

OUR RESPONSIBILITIES

MAINTAIN PRIVACY AND SECURITY

We are required by law to maintain the privacy and security of your protected health information

INFORM OF BREACH

We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

FOLLOW NOTICE PRACTICES

We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

We must follow the duties and privacy practices described in this notice and give you a copy of it. For more information see:
www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html

CHANGES TO THE TERMS OF NOTICE

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

EFFECTIVE DATE
JANUARY 1ST 2009
REVISIONS DATE
FEBRUARY 6TH 2017

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