To contact us:

Phone: 651-455-9697
Fax: 651-455-2012

Notice of Medical Information 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 treatment at this clinic, doctors, nurses and other caregivers may gather information about your medical history and health. This notice will explain how such information may be used and shared with others. It will also explain privacy rights regarding this kind of information.

Most patients of this clinic are children. When we refer to you or your in this Notice, we refer to the patient. When we refer to types of disclosures of information to you, we mean disclosures to the patient, the patient's guardian or person legally authorized to receive information about the patient.

Medical information may be used for the following purposes:

• Treatment: We will use the patient's information to provide, coordinate and manage care and treatment. For example, a physician may share medical information with another physician for consultation or a referral.

• Payment: We will use information to receive payment for the services we provide. For example, we will disclose information in order to submit bills or claims to insurance companies and/or Medicaid.

• Health Care Operations: We will use information for certain activities related to the functioning of this clinic. For example, we may use or disclose information for quality assurance activities.

• Appointment Reminders and Other Health Information: We may use information to send you reminders about future appointments. Information may be used to provide you with information about new or alternative treatments or other health care services that may be of interest to you.

• Fund-Raising: We may use information to notify you about fund-raising drives or other charitable events to raise money for programs for this clinic.

• Family Members or Other Responsible People: We may disclose information to people who will be taking care of the patient or are responsible for paying bills, such as other family members. This clinic will only disclose medical information that these people need to know. We may also use information to let other family members or other responsible people know where the patient is and what their general medical condition is. If the patient is able to make their own health care decisions, this clinic will ask their permission before using medical information for these purposes. If the patient is unable to make health care decisions, this clinic will disclose relevant medical information to family members or other responsible people if we feel it is in the patient¡¦s best interests to do so. For example, we may provide limited medical information to allow another family member to pick up a prescription for the patient.

• Emergency Conditions: Under emergency conditions, we may disclose information about you to the government or other groups that assist in emergencies or disasters.

• Other Uses or Disclosures: This clinic may disclose or use information in the following cases: when required by law; for public health activities; relating to victims of abuse/neglect/domestic violence; for health oversight activities; for judicial and administrative proceedings to the extent permitted by law; for law enforcement purposes, as permitted or required by law; to coroners/medical examiners/funeral directors, as permitted by law; for organ donation purposes; for research purposes under certain circumstances; to avert a serious threat to health or safety; for certain specialized government functions, such as military discharge and national security and intelligence; and for workers' compensation purposes.

• Research: Under certain circumstances, we may use and disclose medical information about you for research purposes. In some cases, we will only disclose information about you for research purposes with your authorization. In other cases, where there is only a minimal risk to your privacy, for example a research project comparing the health and recovery of all patients who received one medication to those who received another, for the same condition, we may disclose information about you without your authorization. All research projects are subject to a special approval process which evaluates each proposed research project and its use of medical information. We will only disclose information about you for research without your authorization when the special approval process results in a determination that there is only a minimal risk to your privacy, and we have initiated processes to protect your privacy to the greatest extent possible.

• This clinic will not use or disclose medical information in any other way unless you allow us to do so in writing. If you do give us permission to use or disclose the patient's medical information for another purpose, you have the right to change your mind and revoke the permission at any time.

Privacy rights:

• Restrict Use and Disclosure: You may request that this clinic not use medical information in certain ways or for certain purposes. You may also request that this clinic not provide medical information to certain people. However, this clinic has the right to refuse your request. This clinic may use or disclose the patient's medical information in situations requiring emergency treatment, in which case we will ask the person(s) who receive the information not to further use or disclose the information.

• Provide Confidentiality: You may request that this clinic provide you with your medical information in a confidential manner. For example, you can request that we send appointment reminders, bills and other mailings to a different address or that we notify you of this kind of information in another way, such as by telephone call. You must make this request in writing and specify another address or means of communication. We must agree to your written request. We may also ask you to give us information on how you will pay your bills.

• Inspection and Copy: You may ask to see and copy your medical records, unless that information is protected by law. You must make these requests in writing. If your request to look at or copy the patient's medical records is denied, you have the right to have the denial reviewed by a health care professional. We will act upon your request within 30 days and may charge you a legally acceptable amount for copying costs.

• Change Information or Amend Medical Records: You may ask us to change information in the patient's medical records. If your request is denied, you can write a statement of disagreement with the denial that we will keep with your medical information.

• Accounting of Disclosures: You may ask us to provide you with information about certain disclosures of your medical information we made in the past. Requests for accountings will not be made prior to April 14, 2003. Your request can go back 6 years after April 14, 2009.

• Paper Copy: If you have received this notice of the medical information privacy rights electronically, you may ask us to provide you with a paper copy.

• Privacy Violations: If you feel your medical information privacy rights have been violated, you may file a complaint with the Secretary of Health and Humans Services and/or with the clinic contact person listed below. Filing a complaint will not affect the quality of the services you receive from this clinic and you will not be retaliated against for filing a complaint.

The U.S. Department of Health and Human Services
200 Independence Avenue S.W.
Washington, D.C. 20201
(202) 619-0257
Toll free: 1-877-696-6775
Electronic: HHS.Mail@hhs.gov
* Contact Person: You can contact the designated privacy official:
Privacy Officer
Address: 5975 Carmen Ave. E.
IGH, MN 55076

Telephone: 651-455-9697

The effective date of this notice is April 14, 2003. This clinic is required by law to maintain the privacy of protected health information and to provide individuals with this notice of its legal duties and privacy practices with respect to health information. This clinic is required to abide by the terms of the notice currently in effect. This clinic reserves the right to change the terms of this notice and to make new notice provisions effective for all protected health information maintained by this clinic. If the terms of this notice are changed, this clinic will provide individuals with a revised notice: at the time of treatment, or upon request, by posting the revised notice in designated locations at this clinic, and by electronically posting on this clinic web site.