HIPAA

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

Why do we ask for private or confidential information?

To establish diagnosis
To determine treatment plans and goals
To treat serious mental health problems in order to reduce or eliminate long-term difficulties for dysfunction for individuals and families.
To coordinate the services you receive from the Center, including assessment of the quality of those services
To provide services you request
To establish your ability to pay or those services and determine eligibility for insurance, grants, and other funding sources
To collect reimbursements for services from third party payers such as insurance companies or social service agencies

Do you have to answer questions?

You are not legally required to provide any of the information we request. In most cases it is to your benefit to provide the information since without it we will be unable to provide some services to you
If you are here because of a court order and you refuse to provide information, that refusal may be communicated to the court
If you do not provide the information we request regarding financial responsibility, you may be responsible for all costs of services we provide to you

With whom may we share information?

Information we maintain about you may be shared with other agencies or individuals under the following circumstances:

A consent for release of information is signed by you
A court order
A statute authorizing release including the Vulnerable Adults and Child Abuse Reporting laws
Your insurance company
To personnel within this agency whose work assignments require access in an emergency, as allowed by law, to communicate your condition to a family member or other appropriate person in accordance with acceptable medical practices.
When your account is severely delinquent, to obtain reimbursement through small claims court or a collection agency.
If you are an inmate, we may disclose your health information to your correctional facility to help provide health care or to provide safety to you or others.
We will disclose information about you without your permission when required to do so by federal, state, or local law.
Other uses of information include appointment reminders, advising you of treatment alternatives, health related benefits and services (workers compensation), research (as authorized by law), and to avert a serious threat to your health and safety.
Other uses and disclosures of information not covered by this notice or the laws that apply to us will be made only with your written authorization and you may cancel your authorization in writing as provided by law.

What are your rights regarding the information we have about you?

You have the right to request restrictions on certain uses and disclosures. We, as the covered entity, are not required to agree to a requested restriction.
You have the right to receive confidential communications of your protected health information.
You should understand that insurance information about you may be sent from the insurance company to the primary policyholder's address.
You have the right to inspect and copy your protected health information.
You have the right to request, in writing, an amendment to your protected health information. We are not required to agree to your request.
You have the right to receive an accounting of disclosures of your protected health information. This is a list of the disclosures we made of information about you.
You have the right to obtain a paper copy of this notice from us upon request.
Most of the data we maintain about you is private. You have the right to view that data if you request. Data will not be shown to you if it is classified as confidential in accordance with Minnesota Statutes, Section 144.335, or classified as confidential investigative data.

If you feel any information we have about you is inaccurate or incomplete, you have a right to file a letter of disagreement. You have the right to dispute the accuracy and completeness of data in your file. The responsible authority of this agency will answer your contest within 30 days of the receipt of your complaint.

You have the right to file an appeal of the decision of the responsible authority if your dispute to the accuracy and completeness of data is not settled to your satisfaction. The appeal should include:Your name, address, phone number;The name and address of this agency and the director's name; Description of the dispute and the data which gave rise to it; Remedy sought. Your letter of appeal should be sent to the Commissioner of Administration, Attention: Data Privacy, 50 Sherburne Ave, St. Paul, MN 55155
What privacy rights do children have?

If you are a minor you have the right to request that private data about you be kept from your parents. You must make this request in writing and explain why you wish this data be withheld and what you expect the consequences of this withholding will be. If this agency agrees that withholding the information from your parents is in your best interest and is allowed by law, it will not be shown to your parents.

Program Appeal Process:
If you feel you have been unfairly denied or excluded from a service program or not given your choice or service, you may appeal for a fair hearing. An appeal form may be obtained from the County Welfare Agency or from the Appeals Office, Department of Human Services, PO Box 54941, St. Paul MN 55155-0941
651-431-3600

(Effective Date: March 2011)
Civil Rights:

You have the right to file a complaint if you feel you have been discriminated against because of race, religion, national origin, sex, marital status, color, creed, disability, or status with regard to public assistance. Complaints may be made to the Department of Human Rights, 190 E 5th St, St. Paul MN 55155, (651) 296-5665.

How to file a complaint?
You have the right to complain if you feel your rights have been violated. If you believe your privacy rights have been violated, you may file a complaint with us by contacting: Executive Director, Northwestern Mental Health Center, Inc., 603 Bruce Street, Crookston, MN 56716, (218) 281-3940.

You may notify the Secretary of the Department of Health and Human Services (HHS) at: Medical Privacy Complaint Division Office for Civil Rights, US Dept. of Health and Human Services, 200 Independence Ave SW, Washington DC 20201. 877-696-6775
You may call the HHS Voice Hotline number at 1-800-368-1019. We will not retaliate in any way in response to your filing a complaint.

The statement of rights applies to your current contact with this agency and all future contacts whether the contact is in person, on the telephone, or by mail. If you have any questions about this statement or any of your rights as described, you may discuss them with your counselor or any other staff person. Specific information about how you can access data, dispute accuracy and completeness of data, request summary data, etc. is available upon request.

Northwestern Mental Health Center, Inc.
Notice of Privacy Practices
(Formerly the Tennessen Warning)

HIPAA

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

Why do we ask for private or confidential information?

To establish diagnosis

To determine treatment plans and goals

To treat serious mental health problems in order to reduce or eliminate long-term difficulties for dysfunction for individuals and families.

To coordinate the services you receive from the Center, including assessment of the quality of those services

To provide services you request

To establish your ability to pay or those services and determine eligibility for insurance, grants, and other funding sources

To collect reimbursements for services from third party payers such as insurance companies or social service agencies

Do you have to answer questions?

You are not legally required to provide any of the information we request. In most cases it is to your benefit to provide the information since without it we will be unable to provide some services to you

If you are here because of a court order and you refuse to provide information, that refusal may be communicated to the court

If you do not provide the information we request regarding financial responsibility, you may be responsible for all costs of services we provide to you

With whom may we share information?

Information we maintain about you may be shared with other agencies or individuals under the following circumstances:

A consent for release of information is signed by you

A court order

A statute authorizing release including the Vulnerable Adults and Child Abuse Reporting laws

Your insurance company

To personnel within this agency whose work assignments require access in an emergency, as allowed by law, to communicate your condition to a family member or other appropriate person in accordance with acceptable medical practices.

When your account is severely delinquent, to obtain reimbursement through small claims court or a collection agency.

If you are an inmate, we may disclose your health information to your correctional facility to help provide health care or to provide safety to you or others.

We will disclose information about you without your permission when required to do so by federal, state, or local law.

Other uses of information include appointment reminders, advising you of treatment alternatives, health related benefits and services (workers compensation), research (as authorized by law), and to avert a serious threat to your health and safety.

Other uses and disclosures of information not covered by this notice or the laws that apply to us will be made only with your written authorization and you may cancel your authorization in writing as provided by law.

What are your rights regarding the information we have about you?

You have the right to request restrictions on certain uses and disclosures. We, as the covered entity, are not required to agree to a requested restriction.

You have the right to receive confidential communications of your protected health information.

You should understand that insurance information about you may be sent from the insurance company to the primary policyholder's address.

You have the right to inspect and copy your protected health information.

You have the right to request, in writing, an amendment to your protected health information. We are not required to agree to your request.

You have the right to receive an accounting of disclosures of your protected health information. This is a list of the disclosures we made of information about you.

You have the right to obtain a paper copy of this notice from us upon request.

Most of the data we maintain about you is private. You have the right to view that data if you request. Data will not be shown to you if it is classified as confidential in accordance with Minnesota Statutes, Section 144.335, or classified as confidential investigative data.

(Effective Date: March 2011)Civil Rights:

Northwestern Mental Health Center, Inc. Notice of Privacy Practices (Formerly the Tennessen Warning)

(Effective Date: March 2011)
Civil Rights:

Northwestern Mental Health Center, Inc.
Notice of Privacy Practices
(Formerly the Tennessen Warning)