The privacy of your health information is important to us.   Bloomington Lake Clinic, Ltd. is required by law to maintain the security and confidentiality of your medical information as well as other identifiable information such as your name, address and telephone number. We are required to extend certain protections to your “Protected Health Information” (PHI) which includes any identifiable information about your past, present, or future health care services or payment for your health care.

We are required by law to provide you with this notice regarding our legal duties and our privacy practices. We are required to abide by the terms of the notice currently in effect. We reserve the right to change our Privacy Practices and the terms of this notice at anytime. For example, if privacy laws change, we will change our practices to comply with the law. Bloomington Lake Clinic, Ltd. will provide you, at your request, a copy of any revised Notice of Privacy Practices at the time of your appointment, in the mail, or you may view the revised Notice of Privacy Practices, which will be posted in our offices.

USES AND DISCLOSURES OF YOUR HEALTH INFORMATION

 Bloomington Lake Clinic, Ltd. is permitted to make uses and disclosures of your protected health information. For some of these purposes, we are required to obtain your consent. For others we may be required to obtain your individual authorization. In a limited number of circumstances we will be authorized by law to disclose your protected health information without your consent or authorization. 

Following is a description of these uses and disclosures:

a . For treatment - We may use or disclose your protected health information to provide and coordinate your care and treatment and any other related services. For example, we will disclose your protected health information as necessary to a health care provider or agency that provides care to you. We may also provide your protected health information to a specialist, laboratory or pharmacy that is involved in your care by providing assistance with diagnosis or treatment.

b. For payment - We may disclose your health information to coordinate claims processing and payment from third party payors. This may include activities such as needed for your health plan to determine eligibility and, benefits and utilization review activities. Information on or accompanying the bill may include information that identifies you as well as your diagnosis, procedures and supplies used.

c . For health care operations - We may disclose your health information to support the business activities of Bloomington Lake Clinic, Ltd. These activities include but are not limited to, quality assessment activities, employee and health care professional review activities, staff training, and other business activities. For example, we may disclose your protected health information by calling you by name in clinic areas, or by asking you to use a sign-in sheet at the registration desk. We may also disclose your protected health information to Bloomington Lake Clinic, Ltd. business associates that perform activities and conduct health care operations on behalf of Bloomington Lake Clinic, Ltd.

 MINNESOTA PATIENT CONSENT FOR DISCLOSURES

 For some disclosures described above we are required by Minnesota law to obtain written consent from you. 

OTHER USES AND DISCLOSURES

 Bloomington Lake Clinic, Ltd. is permitted or required, under specific circumstances, to use or disclose protected health information without your written authorization. These disclosures include those required by law such as:

a. for public health issues such as for reporting of certain communicable diseases or to the state immunization registry

 b. for reporting of abuse or neglect

 c. to government agencies authorized to conduct audits or investigations such as to the Food and Drug Administration for reporting adverse events, or recalls of products

 d. for legal proceedings in response to a court order, and in certain circumstances in response to a subpoena, discovery request or other lawful process

 e. to law enforcement officials in response to a warrant, for the purpose of identifying or locating a suspect, witness or missing person or to provide information concerning victims of crimes

f. in certain instances to coroners and medical examiners during investigations, funeral directors so that they can carry out their duties, and to organizations that handle organ donations.

g.  to researchers if certain measures are taken to protect your health information 

h.  to the extent necessary to avoid a serious health threat to your health or safety or to the health or safety of others 

i.   to armed forces personnel under certain circumstances and to authorized federal officials for national security and intelligence 

j.   to your correctional facility to help provide your health care or to provide safety to you or others, if you are an inmate at a correctional facility 

k.  as required by worker’s compensation laws 

I.   to the Secretary of the Department of Health and Human Services to investigate or determine compliance with the federal requirements for protected health information. 

Other uses and disclosures will be made only with your written authorization, unless otherwise permitted by law and you may revoke such authorization in writing at any time. Your revocation will not affect any uses or disclosures permitted by your authorization while it was in effect. 

Bloomington Lake Clinic, Ltd. may engage in the following activity:

 a. Bloomington Lake Clinic, Ltd. may contact you by telephone or mail to provide test results, appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. 

YOUR INDIVIDUAL RIGHTS 

You have the following rights regarding protected health information: 

a. The right to request restrictions on certain uses and disclosures of protected health information. This means you may ask us not to use or disclose any part of your protected health information. Your request must be in writing and specific in describing the restriction requested and to whom the restriction applies. Bloomington Lake Clinic, Ltd. is not required to agree to a requested restriction, however, if your provider believes it is not in your best interest to restrict the information, your protected health information will not be restricted and you will be notified of this in writing. If your provider does agree to the restriction you will be notified of this in writing and Bloomington Lake Clinic, Ltd. will not use or disclose your protected health information in violation of that restriction unless it is to provide emergency medical treatment. 

b. Periodically, we may contact you by phone, postcard reminders, or other means to the location identified in our records. You have the right to receive confidential communications of protected health information from us by alternative means or at an alternative location. We will make every effort to accommodate reasonable requests to communicate with you. We will not request an explanation from you related to the basis for the request, however, for our records, we will need your request in writing. It is important that you understand that any payment or payment information may be sent to the original address in our records unless you discuss alternative payment options with our business office. 

c. The right to inspect and copy protected health information, as provided in the Privacy Regulation. You may receive a copy of the protected health information contained in your “designated record set” by requesting it in writing. A designated record set includes medical and billing records and any other records that Bloomington Lake Clinic, Ltd. uses to make health care decisions about you, with some specific exceptions. For example, if your provider determines that your records are sensitive, we may not give you access to these records. If your request is denied, we will respond to you in writing explaining why we cannot grant your request and describing your right to request a review of our denial. 

d. The right to ask Bloomington Lake Clinic, Ltd. to amend protected health information that is contained in your “designated record set” as provided in the Privacy Regulation. For our records, the request must be in writing and we ask that it explain, in as much detail as possible, your reason(s) for the amendment and include any supporting documentation if appropriate. In certain circumstances Bloomington Lake Clinic, Ltd. may deny your request for amendment. These include:

• Bloomington Lake Clinic, Ltd. does not have the records you want amended
• Bloomington Lake Clinic, Ltd. did not create the records that you want amended
• Bloomington Lake Clinic, Ltd. determines that the records are accurate and complete
• The records have been compiled in anticipation of a civil, criminal or administrative action or proceeding
• The records are covered by the federal Clinical Laboratory Improvement Act

If Bloomington Lake Clinic, Ltd. denies your request for amendment we will notify you of this in writing. You have the right to file a written statement of disagreement with us and we have the right to rebut that statement. 

e. The right to receive an accounting of disclosures of protected health information. You may request, in writing, information about the times we have disclosed your protected health information for any purpose other than the following exceptions:

• Treatment, payment or health care operations as described previously

• Disclosures that you or your personal representative have authorized

• Certain other disclosures such as disclosures for national security purposes. The requirement that we provide you with information about the times we have disclosed your protected health information applies for six years from the date of the disclosure. This applies to disclosures made on or after April 14, 2003. 

f.   The right to obtain a paper copy of the Notice from Bloomington Lake Clinic, Ltd. upon    request. This right extends to an individual who has agreed to receive the Notice electronically.

Individuals may complain to Bloomington Lake Clinic, Ltd. and to the Secretary of the Department of Health and Human Services, without fear of retaliation by the organization, if they believe their privacy rights have been violated. A brief description of how the individual may file a complaint follows:

 If you feel we may have violated your privacy rights, or you disagree with a decision we made about access to your protected health information, you may either:

• Contact Bloomington Lake Clinic, Ltd.’s Privacy Officer at:

Bloomington Lake Clinic, Ltd.
Attn: Privacy Officer,
3017 Bloomington Ave. So.
Minneapolis, MN 55407
(612) 721-6511

or 

Secretary of Health and Human Services
1 -800-368-1019
Medical Privacy Complaint Division
Office of Civil Rights
U.S. Dept of Health and Human Services
200 Independence Ave. SW
Room 509F, HHH Building
Washington, DC 20201

THIS NOTICE IS FIRST IN EFFECT

ON APRIL 14, 2003.

Copyright Bloomington Lake Clinic, Ltd.