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Our Pledge to You
We understand that medical information about you and your health is personal and we are committed to protecting privacy while providing quality care. This Notice of Privacy Practices applies to all records generated by Mid Dakota Clinic, including departments, medical staff, clinics, employees and affiliated programs and services.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

We are legally required to protect the privacy of your health information. We call this information "Protected Health Information," or (PHI). It includes information that can be used to identify you that we have created or received about your past, present or future health or condition, the provision of health care to you, or the payment for health care services. We must provide you with this notice about our privacy practices that explains how, when, and why we use and disclose your PHI. With some exceptions, we may not use or disclose any more of your PHI than is necessary to accomplish the purpose of the use or disclosure. We are also required to notify affected individuals following a breach of unsecured PHI.

Effective Date of this Notice
The effective date of this notice is August 14, 2015. We reserve the right to change the terms of this notice and our privacy policies. Any changes will apply to the PHI which is currently in our possession. Before we make an important change to our policies, we will promptly change this notice and post a new notice in our main reception areas. You can also request a copy of this notice from our Privacy Officer, (701) 530-6010, or toll-free 1-800-472-2113 ext. 6010.

HOW WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION
We use and disclose PHI for many different reasons. For some of these uses or disclosures, we do not need your written permission (authorization), but for others, we do.

Uses and Disclosures That Do Not Require Your Authorization
We may use and disclose your PHI without your authorization for the following reasons:

• For Treatment
We may obtain and/or disclose your PHI to or from physicians, nurses, medical students, and other health care personnel who provide you with health care services or are involved in your care, including medication history. For example, if you are being treated for a knee injury, we may disclose your PHI to the physical rehabilitation department in order to coordinate your care. We may also share medical information about you in order to coordinate different services you need, such as prescriptions, lab work, and diagnostic testing.

• For Payment
We may use and disclose your PHI in order to bill and collect payment for the treatment and services provided to you. For example, we may provide portions of your PHI to our billing department and your health plan to get paid for the health care services we provided to you. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

• For Health Care Operations
We may disclose your PHI in order to operate this Clinic. For example, we may use your PHI in order to evaluate the quality of health care services that you received or to evaluate the performance of the health care professionals who provided health care services to you. We may also provide your PHI to our accountants, attorneys, consultants, and others in order to make sure we are complying with the laws that affect us. We may also combine the medical information we have with medical information from other similar organizations to compare how we are doing and to see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning who the specific patients are.

• For Legal Proceedings or Law Enforcement
We may disclose your PHI if required by federal, state or local law, for judicial or administrative proceedings, or to assist law enforcement. For example, we make disclosures when a law requires that we report information to government agencies and law enforcement personnel about victims of abuse, neglect, or domestic violence; when dealing with gunshot or other wounds; or when ordered in a judicial or administrative proceeding.

• For Public Health Activities
For example, we report information if required by law about births, deaths, immunizations, and various diseases to government officials in charge of collecting that information. We may provide coroners, medical examiners, and funeral directors necessary information relating to an individual's death.

For Health Oversight Activities
For example, we will provide information to assist the government when it conducts an investigation or inspection of a health care provider or organization.

• For Purposes of Organ Donation
We may notify organ procurement organizations to assist them in organ, eye or tissue donation, or transplants.

For Research Purposes
In certain circumstances, we may provide PHI in order to conduct medical research.

• To Avoid Harm
In order to avoid a serious threat to the health or safety of a person or the public, we may provide PHI to law enforcement personnel or persons able to prevent or lessen such harm.

For Specific Government Functions
We may disclose PHI of military personnel and veterans in certain situations. And we may disclose PHI for national security purposes, such as protecting the president of the United States or conducting intelligence operations.

For Workers' Compensation Purposes
We may share your PHI as permitted or required by state law relating to workers' compensation or other similar programs.

• Appointment Reminders and Health Related Benefits or Services
We may use PHI to provide appointment reminders or to give you information about treatment alternatives or other health care services or benefits we offer.

• Disclosures to Family, Friends, or Others
We may provide your PHI to a family member, friend, or other person whom you indicate is involved in your care or the payment of your health care, if we first provide you with the opportunity to object to the disclosure and you do not object, or if we infer that you do not object to the disclosure. If you are not present when we share your PHI, or you are not able to agree or disagree to our sharing your PHI because you are not capable or there is an emergency circumstance, then we may use our professional judgment to decide that sharing the PHI is in your best interest.

• Participation in CommonWell, NDHIN, and Surescripts
CommonWell is a health information exchange alliance between health care providers on a national level. No PHI is disclosed, however, another provider who is a member of the network may access your PHI from this Clinic or from other providers for treatment purposes only. You may opt out of participation by notifying the Clinic.

NDHIN is a health information network for North Dakota health care providers. It allows other members to securely access your PHI from this Clinic's electronic health record or from other providers for treatment purposes only. You may opt out of participation by completing a form available at the Clinic or at http://www.ndhin.org.

Surescripts is an electronic prescription service between health care providers and pharmacies. Your prescription history is automatically provided to our electronic health record.

Uses and Disclosures That Require Your Authorization
For any purpose other than those described above, we may use or share your PHI only when you grant us your written permission (authorization). For example, we will need an authorization from you before we send your PHI to your life insurance company or disclose psychotherapy notes.


YOUR RIGHTS REGARDING YOUR PHI

The Right to Restrict or Limit Uses and Disclosures
You have the right to ask us to restrict or limit the PHI we use or disclose about you for treatment, payment, or health care operations. We are not required to agree to your restriction request, unless required by law or you have paid for services out-of-pocket, in full, and you ask that we not disclose PHI related to those specific services to your health plan. If we accept your request, we will comply unless the information is needed to provide emergency treatment or disclosure is required by law. Your request for restrictions must be made in writing and submitted to the Clinic's Privacy Officer.

The Right to Receive Confidential Communications
You have the right to ask that we send information to an alternate address (for example, sending information to your work address rather than your home address) or by alternate means (for example, by e-mail instead of regular mail). Your request must be in writing. We will try to grant your request if we feel it is reasonable.

• The Right to Inspect and Copy Your PHI
In most cases, you have the right to look at or get copies of your PHI, but you must make the request in writing. If we do not have your PHI, but we know who does, we will tell you how to get it. We will respond to you within 30 days after receiving your written request. In certain situations, we may deny your request. If we do, we will tell you, in writing, what our reasons are for the denial and explain your right to have the denial reviewed. If you request copies, then we will charge you for the copies. We will also charge you for our postage costs if you ask us to mail the copies to you. For copies of information that are not routinely copied on a standard photocopy machine, such as x-rays or photographs, we charge for the reasonable cost of the copy. If you agree to a summary or explanation of your PHI, then we will charge you a reasonable fee based on our cost of preparing the summary or explanation.

• The Right to Get a List of the Disclosures We Have Made
You may ask for an accounting of certain disclosures of your PHI made by us within the six years prior to the date of your request. We will respond within 60 days of receiving your request. The list will include the date of the disclosure, to whom PHI was disclosed (including their address, if known), a description of the information disclosed, and the reason for the disclosure. We will provide the list to you at no charge, but if you make more than one request during a 12-month period, then we will charge you a reasonable, cost-based fee for each additional request.

• The Right to Amend Your PHI
You have the right to request that we amend your PHI in our medical record files, billing records, and other records used to make decisions about your treatment and payment for your treatment. If you want to amend your records, then you must make the request in writing and provide your reason for the amendment. We will comply with your request unless we believe the information you seek to amend is correct and complete or that other circumstances apply.

• The Right to Get This Notice by E-Mail
You have the right to get a copy of this notice by e-mail. Even if you have agreed to receive this notice by e-mail, you also have the right to request a paper copy of this notice.

• The Right to Revoke Your Written Permission (Authorization)
You may revoke an authorization you gave previously, provided the revocation is in writing. The revocation will not apply to the extent we have already acted in reliance on the authorization. If you revoke your permission, then we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand, however, that we are unable to take back any disclosures we already made with your permission and we are required to retain our records of the care we provided to you.


FOR MORE INFORMATION OR TO REPORT A PROBLEM

If you have questions and/or would like additional information regarding any rights included in this Notice of Privacy Practices, you may contact the Clinic's Privacy Officer at (701) 530-6010 or toll-free 1-800-472-2113 ext. 6010. If you believe your privacy rights have been violated, you may file a complaint with the Clinic's Privacy Officer by calling (701) 530-6010 or toll-free 1-800-472-2113 ext. 6010, or writing to:

Mid Dakota Clinic
Privacy Officer
PO Box 5538
Bismarck, ND 58506-5538


You may also obtain information about how to file a complaint with the Office for Civil Rights at http://www.hhs.gov/ocr/privacy/hipaa/complaints/index.html or at the following numbers:

Voice Phone (800) 368-1019
FAX (303) 844-2025
TDD (800) 537-7697


You may also contact the Region VIII Office for Civil Rights at:

Region VIII Office for Civil Rights
U.S. Department of Health and Human Services
999 18th Street, Suite 417
Denver, CO 80202
Voice Phone 1-800-368-1019
FAX (303) 844-2025
TDD 1-800-537-7697

OCRComplaint@hhs.gov

There will be no retaliation for filing a complaint.