Notice of Privacy Practices
(effective Feb. 17, 2010)
This notice describes how medical information about you may be used and disclosed, and how you can get access to this information. Please review it carefully.
Notice of privacy practices
In this notice, the words “we,” “us” and “Park Nicollet” mean any or all of the following:
- Park Nicollet Methodist Hospital (including its medical staff)
- Park Nicollet Clinic
- Park Nicollet Institute (including International Diabetes Center at Park Nicollet)
- Park Nicollet Melrose Institute
- Park Nicollet Health Care Products
- other parts of the Park Nicollet system that provide health care, and independent providers or contractors who participate in our
organized health care arrangement
“You” means anyone who receives health care services or products from us. “Health information” means any information that we create or receive relating to your health or health care payment, whether oral, written or recorded in any form.
How we may use and disclose your health information
The law requires us to inform you that we use and disclose your health information for the following purposes.
We will use your health information to provide you with health care services or products. We may share your health information with doctors, nurses or other healthcare providers (such as those in X-ray, lab and pharmacy) who are involved in your care and who are part of the entity providing your care. With your consent, we may disclose certain health information specified by you to your family, others involved in your care or organizations outside of Park Nicollet providing health care to you.
We may use and disclose health information to bill:
- your insurer
- any other payer or programs
- your health plan
- Medical Assistance
If your insurer or health plan requires prior approval or other notice to determine whether they will pay for those services or products, we may disclose parts of your health information to them, unless you have asked that we not bill your insurer or plan.
Health care operations
We may use and disclose information about you within Park Nicollet to manage and improve our health-care service. This includes:
- quality assessment
- licensing and accreditation
- business planning and management
- evaluating health professionals
- legal and accounting services
We may provide services with the help of people who are not our employees, and companies that are not our affiliates. This includes equipment technologists, computer hardware and software providers or maintenance personnel. We call these people or companies our “business associates.” We may give our business associates some access to your health information so they can perform their
job duties. We minimize their access as much as possible. They are required to safeguard your information.
Appointment reminders, treatment alternatives
We may use and disclose your health information to provide you with:
- appointment reminders
- information about treatment options and services
- other health-related products or services
If you are a patient at Methodist Hospital or Melrose Institute, we may include the following limited information about you in the hospital directory.
- General condition (fair, stable and others)
How we may use and disclose your health information (cont’d)
This information may be released to people who ask for you by name. You can request that your name or health information be restricted.
People involved in your care
Unless you object, we may release health information to a family member or friend. We also may disclose your health information if you are incapacitated, or in an emergency, if we feel it is in your best interest. We may disclose information about you to a disaster-relief organization if there is a disaster, so your family can be notified.
Your health information may be useful to researchers looking for better ways to diagnose and treat illnesses. For research conducted by a Park Nicollet medical staff member or employee, we will not use or disclose any of your health information for research purposes, unless you give written permission, or a group of people that reviews and approves research (Institutional Review Board) determines your permission is not necessary. For research conducted by anyone who is not a Park Nicollet medical staff member or employee, we will you give you a chance when you register with us, to object to any use or disclosure of your health information for research purposes. Your decision will be respected in all situations.
We may use your health information and disclose your contact information to Park Nicollet Foundation so it can contact you about raising money for one or more nonprofit parts of Park Nicollet. The information we would disclose is limited to your name, address and telephone number, plus the dates you received services from us. We do not sell your information. Any fundraising communication addressed to you will contain instructions describing how you may “opt out” from receiving further similar communications.
If you do not wish to be contacted, please write to: Park Nicollet Foundation, 6500 Excelsior Blvd., St. Louis Park, MN 55426
Required disclosures permitted without your authorization
We will release health information about you as required for workers’ compensation or similar programs to comply with related laws.
Plus, we may need to use or disclose your health information without your authorization:
- to the government for public health activities as permitted or required by law to report disease exposures and statistics, births and
deaths, abuse or neglect, reactions to medication and problems with products
- to a health oversight agency for audits, investigations, inspections and licensure activities
- to prevent a serious and imminent threat to the health or safety of a person or the public, or to help the police apprehend a person involved with a violent crime that may have seriously harmed someone
- to organ donation organizations to assist with organ or tissue donation and transplantation, consistent with applicable law
- to a law enforcement official in response to a court or administrative order, subpoena, warrant, summons or similar process; to
identify or locate a suspect, witness or missing person; to identify a victim of crime if, under certain limited circumstances, we are unable to obtain the victim’s agreement; or in emergency circumstances to report the location and perpetrator of a crime
- to a private party in litigation in response to a valid court order or administrative order
- to a coroner or funeral director as permitted or required by law to identify a deceased person, determine the cause of death or to carry out their necessary duties
- to a correctional institution if you are an inmate, as necessary for your health and the health and safety of other people
- for military, national security or lawful intelligence activities
- otherwise as permitted or required by law
Other uses and disclosures of your health information will be made only with your written authorization. You may revoke that authorization at any time for future uses and disclosures by writing to Park Nicollet Health Information Management/Release of Information at the address at the end of this notice.
Your rights to your health information
You have the following rights regarding the health information we maintain about you.
Rights to inspect and copy
With some exceptions, you have the right to see and request a copy of records that include your health information and are maintained or used by us (the designated record set). To request a copy, write to Park Nicollet Health Information Management/
Release of Information at the address listed at the end of this notice. You may request an electronic copy, if preferred. We charge a fee for copying or mailing costs. In some cases, we may deny your request. If you are denied access to records, you may request that another licensed health care professional chosen by us review the denial. We will comply with the outcome of the review.
Right to request an amendment
You may ask us to amend a record containing your health information if you feel it is incorrect or incomplete. Your request must be submitted in writing to Park Nicollet Health Information Management/Release of Information at the address listed at the end of this notice. You must provide a reason for your request. We may deny your request if, among other reasons, the information was not created by us; is not included in your medical, billing or other records; or is otherwise accurate and complete.
Right to an accounting of disclosures
You have the right to request a written report of where we sent your health information for up to a six-year period. This does not include disclosures to or authorized by you or disclosures for treatment, payment and health care operations as described in
this notice. You must submit your request in writing to Park Nicollet Health Information Management/Release of Information at the address listed at the end of this notice. Your request must state a time period of six years or less, and may not include dates
before April 14, 2003. The first report you request within a 12-month period will be free. After that, we may charge you for the cost of providing the report.
Right to request restrictions
You may request that we restrict or limit the health information we use or disclose about you for treatment, payment or health care operations. We may not be able to comply with your request. If we agree to comply, we will honor your request unless the information is needed to provide emergency treatment. You must make your request in writing to Park Nicollet Health Information Management/
Release of Information at the address listed at the end of this notice. In your request, you must tell us: 1) what information you want to limit; 2) how you want to limit our use or disclosure; and 3) to whom you want the limits to apply. If you pay for services out of pocket, in full, you have the right to request we do not disclose your information in connection with those services to your health plan. To facilitate this restriction, you must make your request at the time of your visit or when services are provided. You will be required at the registration check-in desk to fill out a Request for Confidential/Alternate Billing for Today’s Visit form (15279). Follow instructions on the form.
Right to request confidential communications
You have the right to request that we communicate your health information with you in a certain method or place (such as at work or by mail). You must make your request in writing when you register with us, or to Park Nicollet Health Information Management/Release of Information at the address listed at the end of this notice. We will try to meet all reasonable requests.
Our legal duties and rights
The law requires us to protect the privacy of your health information and to provide this notice of our practices. We reserve the right to change our health information practices and the terms of this notice. We reserve the right to make the changed notice effective
for health information we already have about you and for new information. The notice will contain an effective date on the first page, in the top right-hand corner. The notice will be placed in a prominent place at each of our patient care sites, and it will be posted on our Web site, parknicollet.com. We will replace the notice on our Web site with updated notices as they become available. In addition, you may request a paper copy of this notice by contacting Patient Relations at the address shown on the back of this brochure. Notices will be available whenever we provide you with health care. We also must provide notice of breaches of an individual’s unsecured protected health information which pose a significant risk of harm to the individual.
If you believe your privacy rights have been violated, you may file a complaint with Park Nicollet Health Services Patient Relations at the address shown below. You also may file a complaint with Region V, Office for Civil Rights, U.S. Department of Health and Human Services, 233 N. Michigan Ave., Suite 240, Chicago, IL 60601, or fax 312-886-1807. All complaints must be made in writing. You will not be penalized for filing a complaint.
If you have any questions, contact:
Park Nicollet Health Services
P.O. Box 650
Minneapolis, MN 55440
Park Nicollet Clinic: 952-993-3014
Park Nicollet Methodist Hospital: 952-993-5541
To request a copy of your medical records, contact:
Park Nicollet Health Services
Health Information Management/Release of Information
3800 Park Nicollet Blvd.
St. Louis Park, MN 55416
To request restrictions or confidential communications, contact:
Park Nicollet Health Services
Park Nicollet Health Information Management/Release of Information
Attn: ROI Supervisor
3800 Park Nicollet Blvd.
St. Louis Park, MN 55416