ACMC Notice of Provacy Rights

NOTICE OF MEDICAL INFORMATION PRIVACY RIGHTS
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.
Last updated: 5/18/2011

During your treatment at Affiliated Community Medical Center, P.A. ("ACMC") doctors, nurses, other caregivers and other organizations with which ACMC participates in an organized health care arrangement ("Affiliated Providers") may gather information about your medical history and your current health. The term "ACMC" shall be used throughout this notice to refer collectively to ACMC and its Affiliated Providers. This notice will explain how health information about you may be used by ACMC; how your health information may be shared with others; and your privacy rights regarding this kind of information.

Your medical information may be used and disclosed by ACMC for the following purposes:

Treatment. ACMC may use your information to provide, coordinate, and manage your care and treatment. For example, a physician may share your medical information with another physician for a consultation or a referral. ACMC will get your written consent prior to making disclosures outside ACMC for treatment purposes, except in emergency circumstances when it is not possible to get your consent.

Payment. ACMC may use your information to receive payment for the services we provide. For example, ACMC will disclose information in order to submit bills or claims to insurance companies and/or Medicare or Medicaid. ACMC may also need to tell you health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. ACMC will get your written consent prior to making disclosures for payment purposes.
Health Care Operations. ACMC may use your information for ACMC's health care operations. Health care operations are the uses and disclosures of information that are necessary to run ACMC and make sure that all of our patients receive quality care. For example, ACMC may use or disclose information for quality assurance activities, legal services, underwriting and other business management and administrative activities. ACMC will get your written consent before making disclosures to others outside ACMC for health care operations purposes.
Appointment Reminders and Other Health Information. ACMC may use your medical information to send you reminders about future appointments. Your medical information may also be used to provide you with information about new or alternative treatments or other health care services.

To People Assisting in Your Care. ACMC will only disclose medical information to those taking care of you, helping to pay your medical bills or other close family members or friends. ACMC will only disclose medical information that these people need to know. For example, an ACMC physician may provide limited medical information to allow a family member to pick up a prescription or x-ray for you. ACMC may also use your medical information to let family members or other responsible people know where you are and what your general medical condition is. If you are able to make your own health care decisions, someone on ACMC's staff will ask your permission before disclosing your medical information for these purposes. If you are unable to make health care decisions, ACMC will disclose relevant medical information to family members or other responsible people if we feel it is in your best interest to do so, including in an emergency situation.

Research. Federal law permits ACMC to use and disclose medical information about you for research purposes, either with your specific, written authorization or when the study has been reviewed for privacy protection by an Institutional Review Board or Privacy Board before research begins. In some cases, researchers may be permitted to use information in a limited way to determine whether the study or the potential participants are appropriate. Minnesota law generally requires that the provider obtain the patient's general consent before disclosing the patient's information to an outside researcher. ACMC will make a good faith effort to obtain your consent or refusal to participate in any research study, as required by law, prior to releasing any identifiable information about you to outside researchers.

As Required by Law. ACMC may disclose medical information about you when required by federal, state or local law.
To Avert a Serious Threat to Health or Safety. ACMC may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or to the health and safety of the public or another person. Any disclosure must be only to someone able to help prevent the threat. In addition, Minnesota law generally does not permit these disclosures unless we have your written consent to do so or when the disclosure is specifically required by law, including the limited circumstances in which ACMC health care professionals have a "duty to warn."

To Business Associates. Some services are provided by or to ACMC through contracts with business associates. Examples include ACMC's attorneys, consultants, collection agencies and accreditation organizations. ACMC may disclose information about you to its business associates so that they can perform the job ACMC has contracted with them to do. To protect the information that is disclosed, each business associate is required to sign an agreement to appropriately safeguard the information and not to redisclose the information unless specifically permitted by law.

Your medical information may be released in the following special situations:

Organ and Tissue Donation. ACMC may release your medical information to organizations that handle organ procurement or organ, eye or tissue transplantation, or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation. The information that ACMC may disclose is limited to the information necessary to make a transplant possible.

Military and Veterans. If you are a member of the armed forces, ACMC will release medical information about you as requested by military command authorities if required to do so by law, or when ACMC has your written consent. ACMC may also release medical information about foreign military personnel to the appropriate foreign military command authorities if required to do so by law, or when ACMC has your written consent.

Workers' Compensation. ACMC may release medical information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness. ACMC is permitted to disclose this information to the parties involved in the claim without any specific consent, so long as the information is related to a workers' compensation claim.

Public Health. ACMC may disclose medical information to public health authorities about you for public health activities. These disclosures generally include the following:
- Preventing or controlling disease, injury or disability;
- Reporting births and deaths;
- Reporting child abuse or neglect, or abuse of a vulnerable adult;
- Reporting reactions to medications or problems with products;
- Notifying people of recalls of products they may be using;
- Notifying a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; or
- Reporting to the FDA as permitted or required by law.
Health Oversight Activities. ACMC may disclose medical information to a health oversight agency for health oversight activities that are authorized by law. These oversight activities include, for example, government audits, investigations, inspections, and licensure activities. These activities are necessary for the government to monitor the health care system, government programs and compliance with civil rights laws. Minnesota law requires that patient-identifying information (for example, your name, social security number, etc.) be removed from most disclosures for health oversight purposes, unless you have provided us with written consent for the disclosure.

Lawsuits and Disputes. If you are involved in a lawsuit, dispute, or other judicial proceeding, ACMC will disclose medical information about you only in response to a valid court order, administrative order, or a grand jury subpoena, or with your written consent.

Law Enforcement. ACMC may release medical information if asked to do so by a law enforcement official in response to a valid court order, grand jury subpoena, or warrant, or with your written consent. In addition, ACMC is required to report certain types of wounds, such as gunshot wounds and some burns. In most cases, reports will include only the fact of injury, and any additional disclosures would require your consent or a court order.
We may also release information to law enforcement that is not a part of the health record (in other words, non-medical information) for the following reasons:

To identify or locate a suspect, fugitive, material witness, or missing person;
If you are the victim of a crime, if, under certain limited circumstances, ACMC is unable to obtain your agreement;
About a death ACMC believes may be the result of criminal conduct;
About criminal conduct at one of ACMC's facilities; and
In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

Coroners, Medical Examiners, and Funeral Directors. ACMC will release medical information to a coroner or medical examiner in the case of certain types of death, and ACMC must disclose health records upon the request of the coroner or medical examiner. This may be necessary, for example, to identify you or determine the cause of death. ACMC may also release the fact of death and certain demographic information about you to funeral directors as necessary to carry out their duties. Other disclosures from your health record will require the consent of a surviving spouse, parent, a person appointed by you in writing, or your legally authorized representative.

National Security and Intelligence Activities. ACMC will release medical information about you to authorized federal officials for intelligence, counter-intelligence, and other national security activities only as required by law or with your written consent.

Protective Services for the President and Others. ACMC will disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state, or conduct special investigations only as required by law or with your written consent.

Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, ACMC will release medical information about you to the correctional institution or law enforcement official only as required by law or with your written consent.

Other Uses of Your Medical Information

Except as described above, ACMC will not use or disclose your medical information in any other way without a specific written authorization from you. If you provide us with this written authorization to use or disclose your medical information for another purpose, you may revoke that authorization in writing at any time. If you revoke your authorization, we will no longer use or disclose medical information about you for the reasons covered by your written authorization, except to the extent we have already relied on your authorization. We are unable to take back any disclosures we have already made with your permission, and we are required to retain our records of the care that we provided to you.

You have the following rights regarding medical information we maintain about you:

Right to Request Restrictions. You may request that ACMC not use your medical information in certain ways or for certain purposes. You may also request that ACMC not provide your medical information to certain people. If you pay out-of-pocket in full for an item or service, then you may request that we not disclose information pertaining solely to such item or service to your health plan for purposes of payment or health care operations. We are required to agree with such a request. However, we are not required to agree to any other request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
To request restrictions, you must make your request in writing to the Privacy Officer (see contact information below). In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure, or both; and (3) to whom you want the limits to apply, for example, if you want to prohibit disclosures to your spouse.

Right to Request Confidential Communications. You may request that ACMC provide you with your medical information in a confidential manner. For example, you can request that we send your appointment reminders, bills, and other mailings to a different address or that we notify you of this kind of information in another way, such as by a phone call. You must make this request in writing to the Privacy Officer (see contact information below). We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted, and we may require you to provide information about how payment will be handled.

Right to Inspect and Copy. You have the right to inspect and receive a copy of your medical information that is used to make decisions about your care. Usually, this includes medical and billing records maintained by ACMC.
If you wish to inspect and copy medical information, you must submit your request in writing to: ACMC Health Information Department, 101 Willmar Avenue SW, Willmar MN 56201. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies associated with your request, to the extent permitted by state and federal law. If we maintain your health information in an electronic health record, you have the right to receive a copy of your health information in electronic form. You may also direct us to provide such electronic health information directly to an entity or person clearly and specifically designated by you in writing.
We may deny your request to inspect and copy your information in certain very limited circumstances. For example, we may deny access if your physician believes it will be harmful to your health, or could cause a threat to others. In these cases, we may supply the information to a third party who may release the information to you. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by ACMC will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Right to Request Amendment. If you believe that medical information we have about you is incorrect or incomplete, you have the right to ask us to change the information. You have the right to request an amendment for as long as the information is kept by or for ACMC.
To request a change to your information, your request must be made in writing and submitted to ACMC. In addition, you must provide a reason that supports your request. ACMC may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

Was not created by ACMC, unless the person or entity that created the information is no longer available to make the amendment;
Is not part of the medical information kept by or for ACMC;
Is not part of the information which you would be permitted to inspect and copy; or
Is accurate and complete.

Right to an Accounting of Disclosures. You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of medical information about you. This list will not include disclosures for treatment, payment, and health care operations; disclosures that you have authorized or that have been made to you; disclosures for facility directories; disclosures for national security or intelligence purposes; disclosures to correctional institutions or law enforcement with custody of you; disclosures that took place before April 14, 2003; and certain other disclosures.
To request this list of disclosures, you must submit your request in writing to the Privacy Officer (see contact information below). Your request must state a time period for which you would like the accounting. The accounting period may not go back further than six years from the date of the request, and it may not include dates before April 14, 2003. You may receive one free accounting in any 12-month period. We will charge you for additional requests.

Right to a Paper Copy of this Notice. If you have received this notice of your medical information privacy rights electronically, you may ask ACMC and its Affiliated Providers to provide you with a paper copy. This notice is on our website, www.acmc.com.
Complaints or Questions. If you feel your privacy rights have been violated, you may file a complaint with the Secretary of Health and Human Services, and/or with ACMC and its Affiliated Providers contact person listed below. Filing a complaint will not affect the quality of the services you receive from ACMC and physicians on its staff. You will not be penalized for filing a complaint.

ACMC Privacy Officer
Administratiom
Phone: (320) 231-5050
Address: ACMC-Willmar, 101 Willmar Avenue SW, Willmar MN 56201

Changes to this Notice

ACMC is required by law to maintain the privacy of protected health information in accordance with applicable federal and state laws and to provide individuals with this notice of its legal duties and privacy practices with respect to health information. ACMC is required to abide by the terms of the notice currently in effect.

The effective date of this Notice is April 14, 2003, and it has been updated effective January 10, 2011. ACMC reserves the right to change the terms of this notice and to make a new notice provisions effective for all protected health information maintained by ACMC. If the terms of this notice are changed, ACMC will provide individuals with a revised notice upon request and post the revised notice in designated locations at ACMC.

You can contact the designated privacy official

ACMC Privacy Officer
Administratiom
Phone: (320) 231-5050
Address: ACMC-Willmar, 101 Willmar Avenue SW, Willmar MN 56201

ACMC and its Affiliated Providers are required by law to maintain the privacy of protected health information and to provide individuals with this notice of its legal duties and privacy practices with respect to health information. ACMC and its Affiliated Providers are required to abide by the terms of the notice currently in effect. ACMC and its Affiliated Providers reserve the right to change the terms of this notice and to make a new notice provisions effective for all protected health information maintained by ACMC and/or its Affiliated Providers. If the terms of this notice are changed, ACMC and/or its Affiliated Providers will provide individuals with a revised notice upon request and by posting the revised notice in designated locations at ACMC.