Notice of Privacy Practices

Northwestern Mental Health Center, Inc.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW THIS NOTICE CAREFULLY.

Effective Date:  April 14, 2003

You should know that we are required by law to:

• Make sure that information that identifies you is kept private;

• Give you this notice of our legal duties and privacy practices with respect to information about you;

• Follow the terms of this notice, and

• Notify you if we change the terms of this notice.

Uses and Disclosures:  The following are examples of different ways that we use and disclose information.  Not every use or disclosure is listed.

• We will use information about you to:  1) plan and provide your treatment; 2) to determine your eligibility for insurance, grants or other funding to pay for your care; and 3) to coordinate the services you receive from the Center, including assessment of the quality of those services.  Only persons who need access to this information will be allowed access to carry out these purposes.

• We will disclose information about you without your permission when required to do so by federal, state or local law.  In Minnesota, consistent with the Minnesota Data Practices Act we are required to disclose information about possible child abuse or neglect; possible abuse or neglect of a vulnerable adult; investigations by professional licensing boards; pre-admission screening teams in the case of involuntary hospitalization; in response to a valid court order; in response to certain requests from the Office of the Ombudsman for Mental Health; the Food and Drug Administration; and others.

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

• Other uses of information include appointment reminders, advising you of treatment alternatives, health related benefits and services (worker’s 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.

Individuals Rights

• 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.

Complaint Process

• If you believe your privacy rights have been violated:

• You may file a complaint with us by contacting the person listed below.

• 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 Avenue SW, Room 509F, HHH Building, Washington, DC  20201

• 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.

Contact Person

If you have any questions about this notice, please contact:  Dan Wilson, Executive Director, Northwestern Mental Health Center, Inc., 603 Bruce Street, PO Box 603, Crookston, MN  56716, phone 218-281-3940

For simplicity, this document does not include all procedures and rights related to data practices; clients may have other rights and the Northwestern Mental Health Center may have additional obligations specified in government regulations or in Center policies.