Edina
5500 Lincoln Drive, Suite 100 • Edina, MN 55436 • 952-746-3478
5500 Lincoln Drive, Suite 100 • Edina, MN 55436 • 952-746-3478
Maplewood
2599 White Bear Ave • Maplewood, MN 55109 • 651-243-1850
2599 White Bear Ave • Maplewood, MN 55109 • 651-243-1850
© 2007 Minnesota Community Acupuncture
Minnesota Community Acupuncture
Notice of Privacy Practices, Version 1.1
This Document is only for Reading
Purpose of This Notice
This notice tells you about how your medical information is used and disclosed. It tells you about your rights and our responsibilities to protect the privacy of your medical information. It also tells you how to file a complaint with this office, or with the government if you believe that any of your rights or any of our responsibilities have been violated. This office is required by law to maintain the privacy of your medical information. You must be provided with a copy of this notice and you must provide your signature proving that you have been given the opportunity to review it. We must follow the terms of this notice that are currently in effect. If the notice is changed in any way, a revised notice will be available upon request. These practices may change and those changes may apply to medical information which is already a part of your medical record, as well as any new information.
How Your Medical Information Is Used or Disclosed For Treatment
Your medical information may be used or disclosed to provide you with treatment and services. This information may be shared with others involved in your care such as doctors, nurses, other providers, or health care facilities. Your health information may also be disclosed to a member of your family or other person who is involved in your care. If there is a family member, other relative or close friend to whom you do not want us to disclose your medical information, please notify me in writing (see “Your Rights” section below).
For Payment: Your medical information may be used or disclosed to bill and collect payment for the services and products provided to you. For example, you or a third-party payer may be sent a bill that includes accompanying information about your diagnosis, treatment and the supplies used. A third-party payer may also be contacted to confirm your coverage or to request prior approval for a planned treatment or service.
For Health Care Operations: Your medical information may also be used or disclosed for operational purposes. For example, your medical information may be used to evaluate our services and to improve the quality and effectiveness of our healthcare services. You may be contacted at any phone number or address you have provided to remind you of an appointment, to discuss healthcare matters, or to obtain payment for services. Phone or email messages may be left for you. If you want to be contacted in a certain way or at a certain location, see “Rights to Receive Confidential Communications” below in this notice.
There are some services that are provided for us by our business associates such as accountants, consultants and attorneys. Whenever we share information with our business associates we have a written contract with them that requires that they protect the privacy of your medical information.
Other Uses and Disclosures of Your Medical Information
Newsletter, Healthcare Information, and Treatment Alternatives: Your name, address, and/or email address may be added to a mailing list of patients in order to inform you of important health information, services, and activities. If you do not want to receive these communications, please notify us in writing.
Publication: The data incident to or obtained from your health record and treatments may be used for any medical, scientific or educational study, research, or published work. Confidentiality and anonymity will be preserved at all times.
Use or Disclosures That Are Required or Permitted by Law
Your medical information may be used for any uses that are required or permitted by law, for example:
• Public Health: Your medical information may be disclosed to public health and/or legal authorities if it is necessary to prevent a threat to the health or safety of a person or the general public.
• Food and Drug Administration: Your medical information may be disclosed, as required by law, to report any adverse effects of food, supplements, products, and product defects controlled by the Food and Drug Administration.
• Law Enforcement: Your medical information will be disclosed as required by law; in response to a court order or other legal proceeding; to identify or locate a suspect, fugitive, material witness or missing person; in reference to crimes that occur on our premises; in order to report a crime or emergency circumstances; when information is requested about an actual or suspected crime.
• Health Oversight: Your medical information may be disclosed, as required by law, to a health oversight agency.
Use or Disclosures That Require Your Authorization
Other uses and disclosures will be made only with your written authorization. You may cancel authorization at any time by notifying us in writing. If you cancel an authorization, it will not have an effect on information that has already been disclosed. Some examples of uses or disclosures that would require your written authorization are:
• A request to provide your medical information to an attorney for use in a civil lawsuit.
• A request to provide medical information to a supplement company for marketing purposes.
Your Rights
Your health or medical record is the physical property belonging to this office. The information in it belongs to you. You have the following rights:
Right to Request Restrictions: You have the right to request that your medical information not be used or disclosed for a particular reason related to treatment, payment or our operations. You may ask that family members or other individuals not be informed of specific medical information. Requests must be made in writing. We do not have to agree to your request. If we agree to your request, we must keep the agreement, except in the case of a medical emergency. You can stop the restriction at any time through another written request.
Right to Receive Confidential Communications: You have the right to ask that we communicate with you in a certain way or at a certain place. If you want to request confidential communications, the request must be made in writing. We must agree to your request, if it is reasonable.
Right to Inspect and Copy Your Medical Information: You have the right to ask to inspect and obtain a copy of your medical information. You must submit your request in writing. We may charge a fee for the costs of copying, summarizing, and mailing it to you. We may deny this request under certain limited circumstances. If your request is denied, we will inform you in writing and you may request a review of our denial.
Right to Request Amendments to Your Medical Information: You have the right to request that we correct your medical information. If you believe that any medical information in your record is incorrect or that important information is missing, you must submit your request in writing. We may deny your request if we determine that the information:
• Was not created by us
• Is not part of the medical information that we maintain
• Is in records that you are not allowed to inspect and copy
• Is already accurate and complete
Right to An Accounting Of Disclosure of Health Information: You have the right to find out what disclosures of your medical information have been made. This list of disclosures is called an accounting. The accounting may be for up to six years prior to the date on which you request the accounting, but cannot include disclosures made before April 28, 2003.
We are not required to include disclosures for treatment, payment or healthcare operations or certain other exceptions. Request for an accounting of disclosure must be submitted in writing. You are entitled to one free accounting in any twelve month period. We may charge you for the cost of providing additional accountings.
Right to Obtain a Copy of the Notice: You have the right to ask for and get a paper copy of this notice and any revisions we make to the notice at any time. Revised notices are also available online at www.minnca.com
Complaints
You have the right to complain to this office and to the U.S. Secretary of Health and Human Services if you believe your privacy rights have been violated. There is no risk involved if you file a complaint. To file a complaint, contact us in writing by mail:
Minnesota Community Acupuncture
5500 Lincoln Dr. Ste 100
Edina, MN 55436
To file a complaint with the government, send your complaint in writing by mail to:
Office of Civil Rights
U.S. Department of Health and Human Services
200 Independence Ave., SW
Washington, DC 20201
Attn: U.S. Secretary of Health and Human Services
Notice of Privacy Practices, Version 1.1
This Document is only for Reading
Purpose of This Notice
This notice tells you about how your medical information is used and disclosed. It tells you about your rights and our responsibilities to protect the privacy of your medical information. It also tells you how to file a complaint with this office, or with the government if you believe that any of your rights or any of our responsibilities have been violated. This office is required by law to maintain the privacy of your medical information. You must be provided with a copy of this notice and you must provide your signature proving that you have been given the opportunity to review it. We must follow the terms of this notice that are currently in effect. If the notice is changed in any way, a revised notice will be available upon request. These practices may change and those changes may apply to medical information which is already a part of your medical record, as well as any new information.
How Your Medical Information Is Used or Disclosed For Treatment
Your medical information may be used or disclosed to provide you with treatment and services. This information may be shared with others involved in your care such as doctors, nurses, other providers, or health care facilities. Your health information may also be disclosed to a member of your family or other person who is involved in your care. If there is a family member, other relative or close friend to whom you do not want us to disclose your medical information, please notify me in writing (see “Your Rights” section below).
For Payment: Your medical information may be used or disclosed to bill and collect payment for the services and products provided to you. For example, you or a third-party payer may be sent a bill that includes accompanying information about your diagnosis, treatment and the supplies used. A third-party payer may also be contacted to confirm your coverage or to request prior approval for a planned treatment or service.
For Health Care Operations: Your medical information may also be used or disclosed for operational purposes. For example, your medical information may be used to evaluate our services and to improve the quality and effectiveness of our healthcare services. You may be contacted at any phone number or address you have provided to remind you of an appointment, to discuss healthcare matters, or to obtain payment for services. Phone or email messages may be left for you. If you want to be contacted in a certain way or at a certain location, see “Rights to Receive Confidential Communications” below in this notice.
There are some services that are provided for us by our business associates such as accountants, consultants and attorneys. Whenever we share information with our business associates we have a written contract with them that requires that they protect the privacy of your medical information.
Other Uses and Disclosures of Your Medical Information
Newsletter, Healthcare Information, and Treatment Alternatives: Your name, address, and/or email address may be added to a mailing list of patients in order to inform you of important health information, services, and activities. If you do not want to receive these communications, please notify us in writing.
Publication: The data incident to or obtained from your health record and treatments may be used for any medical, scientific or educational study, research, or published work. Confidentiality and anonymity will be preserved at all times.
Use or Disclosures That Are Required or Permitted by Law
Your medical information may be used for any uses that are required or permitted by law, for example:
• Public Health: Your medical information may be disclosed to public health and/or legal authorities if it is necessary to prevent a threat to the health or safety of a person or the general public.
• Food and Drug Administration: Your medical information may be disclosed, as required by law, to report any adverse effects of food, supplements, products, and product defects controlled by the Food and Drug Administration.
• Law Enforcement: Your medical information will be disclosed as required by law; in response to a court order or other legal proceeding; to identify or locate a suspect, fugitive, material witness or missing person; in reference to crimes that occur on our premises; in order to report a crime or emergency circumstances; when information is requested about an actual or suspected crime.
• Health Oversight: Your medical information may be disclosed, as required by law, to a health oversight agency.
Use or Disclosures That Require Your Authorization
Other uses and disclosures will be made only with your written authorization. You may cancel authorization at any time by notifying us in writing. If you cancel an authorization, it will not have an effect on information that has already been disclosed. Some examples of uses or disclosures that would require your written authorization are:
• A request to provide your medical information to an attorney for use in a civil lawsuit.
• A request to provide medical information to a supplement company for marketing purposes.
Your Rights
Your health or medical record is the physical property belonging to this office. The information in it belongs to you. You have the following rights:
Right to Request Restrictions: You have the right to request that your medical information not be used or disclosed for a particular reason related to treatment, payment or our operations. You may ask that family members or other individuals not be informed of specific medical information. Requests must be made in writing. We do not have to agree to your request. If we agree to your request, we must keep the agreement, except in the case of a medical emergency. You can stop the restriction at any time through another written request.
Right to Receive Confidential Communications: You have the right to ask that we communicate with you in a certain way or at a certain place. If you want to request confidential communications, the request must be made in writing. We must agree to your request, if it is reasonable.
Right to Inspect and Copy Your Medical Information: You have the right to ask to inspect and obtain a copy of your medical information. You must submit your request in writing. We may charge a fee for the costs of copying, summarizing, and mailing it to you. We may deny this request under certain limited circumstances. If your request is denied, we will inform you in writing and you may request a review of our denial.
Right to Request Amendments to Your Medical Information: You have the right to request that we correct your medical information. If you believe that any medical information in your record is incorrect or that important information is missing, you must submit your request in writing. We may deny your request if we determine that the information:
• Was not created by us
• Is not part of the medical information that we maintain
• Is in records that you are not allowed to inspect and copy
• Is already accurate and complete
Right to An Accounting Of Disclosure of Health Information: You have the right to find out what disclosures of your medical information have been made. This list of disclosures is called an accounting. The accounting may be for up to six years prior to the date on which you request the accounting, but cannot include disclosures made before April 28, 2003.
We are not required to include disclosures for treatment, payment or healthcare operations or certain other exceptions. Request for an accounting of disclosure must be submitted in writing. You are entitled to one free accounting in any twelve month period. We may charge you for the cost of providing additional accountings.
Right to Obtain a Copy of the Notice: You have the right to ask for and get a paper copy of this notice and any revisions we make to the notice at any time. Revised notices are also available online at www.minnca.com
Complaints
You have the right to complain to this office and to the U.S. Secretary of Health and Human Services if you believe your privacy rights have been violated. There is no risk involved if you file a complaint. To file a complaint, contact us in writing by mail:
Minnesota Community Acupuncture
5500 Lincoln Dr. Ste 100
Edina, MN 55436
To file a complaint with the government, send your complaint in writing by mail to:
Office of Civil Rights
U.S. Department of Health and Human Services
200 Independence Ave., SW
Washington, DC 20201
Attn: U.S. Secretary of Health and Human Services
By clicking the links below I acknowledge that I have read and I understand this Notice of Privacy Practices
PRINT: New Patient Forms for Women
PRINT: New Patient Forms for Men
PRINT: New Patient Forms for Women
PRINT: New Patient Forms for Men
By clicking the links below I acknowledge that I have read and I understand this Notice of Privacy Practices
PRINT: New Patient Forms for Women
PRINT: New Patient Forms for Men
PRINT: New Patient Forms for Women
PRINT: New Patient Forms for Men