YOUR INFORMATION. YOUR RIGHTS. OUR RESPONSIBILITIES.
We learn about you as we care for your health. Some of what we learn becomes part of your health information. We work hard to protect the privacy of your health information and we have rules for our employees on how to manage this information. This Notice of Privacy Practices describes how your health information may be used and disclosed by our office and also how you may access and control your health information.
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
COPY OF MEDICAL RECORD
Receive an electronic or paper copy of your medical record:
- You can make a request in writing to see or copy an electronic or paper copy of your medical record and other health information we have about you, with the exception of information protected by law. Ask us how to do this .
- We will provide a copy or a summary of your health information within a reasonable time .
- There also may be a reasonable charge for copies.
REQUEST TO AMEND MEDICAL RECORD
Ask us to correct your medical record:
- You can request in writing to correct health information about you that you think is incorrect or incomplete. Ask us how to do this .
- We may say “no” to your request, but we’ll tell you why in writing within 60 days. If your request is denied, you may write a statement of disagreement with the denial that we will keep with your health information.
REQUEST CONFIDENTIAL COMMUNICATIONS
Request for us to contact you confidentially:
- You can request in writing to contact you in a specific way (for example, home or office phone) or to send mail to a different address .
- We will say “yes” to all reasonable requests
REQUEST TO LIMIT USE/SHARING OF TPO
Ask us to limit what we use or share:
- You can make a request in writing not to use or share certain health information for treatment, payment, or our operations (TPO). We are not required to agree to your request, and we may say “no” if it would affect your care .
- If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
ACCOUNTING OF DISCLOSURES
Get a list of those with whom we’ve shared information:
- You can request in writing for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
- We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). with your health insurer. We will say “yes” unless a law requires us to share that information.
COPY OF THIS PRIVACY NOTICE
Get a copy of this privacy notice:
You can request a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
FILE A COMPLAINT
File a complaint if you feel your rights are violated:
- You can file a complaint if you feel we have violated your rights by contacting our Privacy Official using the information listed under Other Instructions for Notice section.
- You can file a complaint with the U .S . Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S .W., Washington, D .C. 20201, calling 1-877-696-6775, or visiting
- We will not retaliate against you for filing a complaint.
REQUEST US NOT TO SHARE
For certain health information, you can tell us your choices about what we share:
If you have a clear preference for how we share your information in the situations described below, talk to us .Tell us what you want us to do, and we will follow your instructions . In these cases, you have both the right and choice to tell us NOT to:
- Share information with your family, close friends, or others involved in your care
- Share information in a disaster relief situation
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
WILL NEVER SHARE WITHOUT PERMISSION
In these cases we never share your information unless you give us written permission:
- Marketing purposes
- Sale of your information
In the case of fundraising:
- We may contact you for fundraising efforts, but you can tell us not to contact you again.
OUR USES AND DISCLOSURES
USES AND DISCLOSURES FOR TPO
How do we typically use or share your health information?
We typically use or share your health information in the following ways . We need your consent before we disclose protected health information for treatment, payment, and operations purposes, unless the disclosure is to a related entity, or the disclosure is for a medical emergency and we are unable to obtain your consent due to your condition or the nature of the medical emergency. [Minn. Stat. § 144.293, subd. 2 and 5]
We can use your health information and share it with other professionals who are treating you only if we have your consent. We can only release your health records to health care facilities and providers outside our network without your consent if it is an emergency and you are unable to provide consent due to the nature of the emergency. We may also share your health information with a provider in our network. [Minn. Stat. § 144.293, subd. 2 and 5] Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Run Our Organization
We can use and share your health information to run our practice, improve your care, and contact you when necessary . We are required to obtain your consent before we release your health records to other providers for their own health care operations. [Minn. Stat. § 144.293, subd. 2 and 5] Example: We use health information about you to manage your treatment and services.
Bill For Your Services
We can use and share your health information to bill and get payment from health plans or other entities only if we obtain your consent. [Minn. Stat. § 144.293, subd. 2 and 5] Example: We give information about you to your health insurance plan so it will pay for your services.
OTHER USES AND DISCLOSURES
How else can we use or share your health information?
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see:
PUBLIC HEALTH AND SAFETY
Help with public health and safety issues
We can share health information about you for certain situations such as:
- Preventing disease
- Helping with product recalls
- Reporting adverse reactions to medications
- Reporting suspected abuse, neglect, or domestic violence
- Preventing or reducing a serious threat to anyone’s health or safety
We can use or share your information for health research if you do not object. [Minn. Stat. § 144.295 subd. 1]
COMPLY WITH THE LAW
Comply with the law
We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law . [Minn. Stat. § 144.293 subd. 2]
ORGAN AND TISSUE DONATION
Respond to organ and tissue donation requests
We can share health information about you with organ procurement organizations only with your consent. [Minn. Stat. § 525A.14]
Work with a medical examiner or coroner
We can share health information with a coroner and medical examiner when an individual dies . We need consent to share information with a funeral director. [Minn. Stat. § 390.11 subd. 7 (a)]
WORKERS’ COMP, LAW ENFORCEMENT, GOVERNMENT
Address workers’ compensation, law enforcement, and other government requests
We can use or share health information about you:
- For workers’ compensation claims
- For law enforcement purposes or with a law enforcement official with your consent, unless required by law. [Minn. Stat. § 144.293, subd. 2]
- With health oversight agencies for activities authorized by law
- For special government functions such as military, national security, and presidential protective services with your consent, unless required by law.[Minn. Stat. § 144.293, subd. 2]
RESPOND TO LEGAL ACTIONS
Respond to lawsuits and legal actions
We can share health information about you in response to a court or administrative order, or in response to a subpoena. [Minn. Stat. § 144.293, subd. 2]
MAINTAIN PRIVACY & SECURITY
We are required by law to maintain the privacy and security of your protected health information.
INFORM OF BREACH
We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
FOLLOW NOTICE PRACTICES
We must follow the duties and privacy practices described in this notice and give you a copy of it.
We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see:
CHANGES TO THE TERMS OF THIS NOTICE
CHANGES TO THE TERMS OF NOTICE
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our website.
OTHER INSTRUCTIONS FOR NOTICE
NAME AND CONTACT OF PRIVACY OFFICIAL
CRL Privacy Officer, 7595 Anagram Drive, Eden Prairie, MN 55344, 952‐285‐3715 or email@example.com
LIST OF ENTITIES COVERED BY THIS NOTICE
Organizations Covered by this Notice:
CRL Imaging Southdale