This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review this notice carefully.

If you have any questions about this Notice of Privacy Practices or Your Rights as described in this Notice, please contact our Office Manager by calling 320-229-1500.

Your personal health and medical information is defined as Protected Health Information (PHI) by a federal law known as HIPAA. More specifically, PHI is information about you, including demographic information that may identify you and information that relates to your past, present, and future condition or health, mental or physical, and other related healthcare services.

This notice of Privacy Practices (NOTICE) describes how our clinic may use and disclose your PHI to provide treatment, obtain payment or carry out healthcare operations and for other purposes permitted or required by law. This notice also describes your rights as a patient to access and control your health information.
Interventional Pain & Physical Medicine Clinic (we or clinic) is required to abide by the terms of this notice. Our clinic may change terms of our notice, at such time as needed. If we change this notice, we will change our practice of handling PHI to comply with the changed notice as of its effective date. You may request a revised copy of the notice by calling our Privacy Officer or by visiting our office and requesting that a revised copy be sent to you.

Treatment:

We may use your PHI to provide you with healthcare treatment and/or services. We may disclose your health information to physicians, nurses, technicians, health students, therapists, or any other personnel who are part of your care. For example, we may disclose your PHI, as necessary to another physician who may be treating you for health needs. We may also disclose your PHI for purposes of consultation, to obtain x-rays to perform lab tests, to prepare prescriptions or for any other treatment purpose.

We may disclose you PHI by calling you by name in the waiting room when you are ready to be seen for your office visit. We may use or disclose your PHI, to contact you and to remind you of your appointments.

Payment:

Our clinic will use your PHI to obtain payment for your healthcare services. For example, we may need to give your health plan or coverage program information about your care and treatment so that our Clinic will be paid or for you to be reimbursed for the charges related to the services we provided. In addition, we may share your PHI with your health plan or coverage program to obtain prior approval or to determine whether or not your health plan or coverage program will cover the treatment or procedure being planned or considered.

Healthcare Operations:

Our Clinic may use or disclose your PHI to support necessary business activities. These business activities include quality assurance programs, employee review scenarios and/or training of staff. We may use your PHI to review our treatment and services and to evaluate our performance in caring for you. For example, we may use PHI to aggregate data and information to determine whether our Clinic should provide new or additional services, if certain services should be discontinued, whether certain procedures or treatment protocols are effective, or to periodically assess the need for any focused improvement efforts.

Business Associates:

We will share your PHI with certain contractors, defined under the Privacy Rule as Business Associates, to perform activities necessary to treatment, payment, and/or healthcare operations. However, in these instances, we will maintain a written agreement with such Business Associates to protect your PHI from unlawful uses or disclosures.

Required by Law:

We may use or disclose your PHI to the extent that the use or disclosure is required by federal, state or local law. The use or disclosure will be made in compliance with law and will be limited to the relevant requirements. You will be notified of any such uses or disclosures when the law requires such notification.

Minnesota Department of Health

We may disclose your PHI for certain public health programs to a public health authority that is permitted by law to collect or receive your health information. This disclosure will be made for the purpose of controlling disease, injury or disability. We may also disclose your PHI, if directed by the appropriate public health authority, to a foreign government agency that is working with a public health authority.

Communicable Diseases:

We may disclose your PHI, if authorized by law, to individuals who may have been exposed to a communicable disease or who may be at risk of contracting or spreading the disease or condition.

Health Oversight

We may disclose your PHI to a health oversight agency for activities authorized by law, such as those related to investigations and inspections. Oversight agencies seeking this information include government agencies that oversee the healthcare system, government benefit programs, and other government regulatory programs and civil rights laws.

Abuse or Neglect

Our Clinic must disclose your PHI to a human services or law enforcement authority authorized by law to receive reports of child abuse or neglect. We must disclose your PHI if we believe in good faith that you have been a victim of abuse, neglect, or domestic violence and such disclosure is to a government agency authorized to receive such information. Such disclosure will comply with the requirements in federal and state laws.

Food and Drug Administration

Our Clinic may disclose your PHI due to an incident related to and as required by the Food and Drug Administration to report adverse events, product defects or problems, biological produce deviation, to track FDA-regulated products, to enable product recalls, repairs or replacements, to conduct post-marketing surveillance and for look-back, i.e., to locate and notify persons having received products since withdrawn or recalled.

Legal Proceeding

We may disclose your PHI in the course of judicial or administrative proceedings, in response to an order of a court or tribunal (to the extent expressly authorized), and in certain conditions in response to a subpoena, discovery request, or other lawful processes.

Law Enforcement

We may disclose your PHI when necessary for law enforcement purposes and when applicable legal standards and requirements have been met. These purposes include requests for information for (1) legal processes required by law; (2) identifications and location purposes; (3) victims of a crime; (4) suspicions that death has occurred as a result of criminal behavior; (5) crimes that have occurred on our Clinic premises; and (6) if a medical emergency arises away from our Clinic premises and it is likely that a crime has occurred.

Coroners, Funeral Directors and Organ Donation

Our Clinic may disclose your PHI to a coroner or medical examiner for identifications purposes, to determine cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose your PHI to a funeral director, as authorized by law, to permit the funeral director to carry out necessary duties. We may disclose information in reasonable anticipation of death. In addition, your PHI may be used and disclosed if you are an organ, eye, tissue, or cadaver donor.

Research

If you are participating in a clinical research program approved by an Institutional Review Board (IRB) and if you have signed a specific research participation agreement and consent form that has been provided to our Clinic, then we may disclose your PHI to the designated researchers in conformance with the established research collection protocols.

Criminal Activity

Where applicable federal and state laws indicate, our Clinic may disclose your PHI if we believe the use or disclosure is necessary to prevent or lesson a serious and imminent threat to the threat to the health or safety of a person or the public. We may also disclose your PHI if it is necessary for law enforcement authorities to identify or apprehend an individual.

Inmates

Our Clinic may use or disclose your PHI if you are an inmate of a correctional facility and our Clinic created or received your PHI in the course of providing care to you.

Military Activity and National Security: In certain situations, our Clinic may use or disclose your PHI if you are deemed to be Armed forces personnel in the following situations: (1) for activities deemed necessary by appropriate military command authorities; (2) for a determination by the Department of Veteran Affairs of you eligibility for benefits; or (3) to a foreign military authority if you are a member of that foreign military service. We may also disclose your PHI to authorized officials conducting national security or intelligence activities including the provision of protective services to the President or others as authorized by law.

Workers Compensation

Our Clinic may disclose your PHI to comply with worker compensation laws and other similar programs established by law.

Required Use and Disclosures: The Privacy Rule mandates that we make disclosures when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the Privacy Rule and the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Specifically, the requirements of Section 164.500 et seq.

Health-Related Services and Treatment Alternatives

We may use your PHI to inform you about health-related services, options, or alternatives that may be helpful to you.

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION

Our Clinic understands that your PHI and matters related to your health are personal. We are committed to protecting your PHI and to informing you about your rights in respect to your PHI. The following statements related to your rights, your PHI, and how you may exercise your rights.

If you have questions about this Notice of Privacy Practices or Your Rights as described below, please contact our Office Manager by calling (320) 229-1500. If you have special requests, restrictions, or directions for us to consider or coordinate in respect to your PHI, this Notice, or Your Rights, you must communicate with us in a writing that is signed, dated and addressed to:

Interventional Pain & Physical Medicine Clinic
Attn: Office Manager
2025 Stearns Way, Suite 114
Saint Cloud, MN 56303

Right to Request Restrictions on Uses and Disclosures

You have the right to ask our Clinic not to use or disclose any part of your PHI for the purposes of treatment, payment or healthcare operations. You also have the right to request our Clinic to restrict the use or disclosure of PHI to family members or personal representatives. However, we are not required to agree to any restriction you may request. But, if we do agree to your requested restriction and believe it to be in your best interest, we may not violate your requested restriction except as necessary to the delivery of emergency medical care. Requests are to be made in writing to our Office Manager.

Right to Access Your PHI

In most cases, you have the right to inspect and obtain a copy of PHI that we maintain about you. To receive a copy of your PHI, we may charge you the cost of copying, mailing and supplies associated with your request. Certain types of PHI will not be available for inspection and copying. This includes PHI collected by us in connection with or in reasonable anticipation of legal claims or proceedings. In limited circumstances we may deny your request to inspect and obtain a copy of your PHI. If we deny your request to inspect and copy, you may request that the denial be reviewed. An individual chosen by our Clinic who is not involved in the original decision to deny your request will conduct the review. Our Clinic will comply with the outcome of the review. In these matters, write to our Office Manager.

Right to Amend Your PHI

You have the right to request that your PHI be amended if you believe your PHI maintained by our Clinic is incorrect or that an important part of your PHI is missing. We may deny your request if your request is not in writing or does not include a reason that supports your request. If your request to amend your PHI is declined, you have the right to prepare a statement of disagreement to be included with your PHI. At our discretion, we have the right to include a rebuttal to your statement with your PHI; however, we will provide you with a copy. In regard to your right to amend your PHI, write to our Office Manager.

Right to Receive an Accounting of Disclosure

You have a right to request an accounting of the disclosures of your PHI that our Clinic has made, if any, for reasons other than disclosures for treatment, payment, healthcare operations or disclosures that have been made pursuant to proper authorization by you. Your right to an accounting of our Clinic's disclosures of your PHI applies only to your PHI created after April 14, 2003 and cannot exceed a period of six (6) years prior to the date of your request. The initial accounting you request within a twelve (12) month period will be free. However, we may charge you for any additional accounting requests. We will notify you of the cost involved and you may choose to withdraw or modify your request before any costs are incurred. Regarding these requests, write to our Office Manager.

Right to Receive Confidential Information

You have the right to request communications involving your PHI be provided to you at an alternative location or by an alternative means of communication. Our Clinic is required to accommodate any reasonable request if the normal method of disclosure may endanger you. Write to our Office Manager with this request and briefly describe the reason for your request.

Right to File a Complaint

You have the right to file a complaint with our Clinic or to the Secretary of Health and Human Services if you believe your privacy rights have been violated. All complaints must be submitted in writing. You will not be penalized or retaliated against in any way for filing a complaint. If you have questions on filing a complaint, please contact our Office Manager by calling (320) 229-1500. Submit complaints in writing to our Office Manager.
Right to Receive a Paper Copy of This Notice: (Click to Expand)
Upon request, even if you have previously agreed to accept this Notice electronically, you have a right to request a paper copy of this Notice. Make such requests in writing addressed to our Office Manager.

Effective Date of Notice

This notice was published and made effective April 14, 2003.

Additional Information or Change to This Notice: We reserve the right to add information or change the terms of this Notice at any time. The effective date of this Notice and any revised Notice may be found on the last page at the bottom right hand corner of this Notice. You may request a copy of a revised Notice by mail or email, but we will only deliver the Notice by email if email delivery is offered by our Clinic and if you have agreed to such delivery. A copy of our Notice is also available at our Clinic. Write to our Office Manager for a copy of this Notice.

Further Information

You may have other rights under various but related laws. You may always request information on our policies and practices by writing to our Office Manager.

Patient Acknowledgement of Receiving Notice of Privacy Practices and Clinic Documentation
You will be requested to acknowledge your receipt of this Notice of Privacy Practices by signature on a form designed for that purpose. Our Clinic will retain that form, once signed by you, within the medical record established for you by our Clinic. If you refuse or are unable to sign the acknowledgement form that we provided you with this Notice, we will document your medical record accordingly as part of our good faith effort to promote your review and understanding of this Notice of Privacy Practices.

Effective Date: 4/14/2003