LAKE SUPERIOR COMMUNITY HEALTH CENTER

NOTICE OF

PRIVACY PRACTICES

Effective April 14, 2003

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED, DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORAMTION. PLEASE READ IT CAREFULLY.

In this Notice, the works “LSCHC,” “we” “us,” and “our” mean any or all of the following:

“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.

Purpose of this Notice

This Notice describes our privacy practices and how we protect the confidentiality of your information. We are required by law to maintain the privacy of your health information and give you this Notice about our legal duties and privacy practices. We must follow our Notice that is currently in effect. We reserve the right to change the terms of this Notice. Any changed Notice will be effective for health information we already have about you, as well as for new information. The Notice will contain an effective date on the first page, in the top right-hand corner. We will post the current Notice in a prominent place at each or our locations. In addition, we will make a paper copy of this Notice available at each of our locations.

Uses and Disclosures of Your Health Information

We may use and disclose your health information for the following purposes:

Treatment: We will use and disclose your health information to provide, coordinate, or manage your health care and any related services or products. For example, we may disclose information about you to doctors, nurses, social workers, other clinicians and professionals in training to coordinate and provide you with things such as prescriptions, lab work, x-rays or referrals.

Payment: We may use and disclose your health information to obtain payment for your care services. For example, we may tell your health plan or medical insurer about treatment you have received or are going to receive in order to obtain payment or determine whether your insurance plan will cover it.

Health Care Operations: We may use and disclose information about you to support and improve our healthcare services to you. These activities may include, but are not limited to quality assessment activities, licensing, business planning and management activities.

Some examples include:

We may contact you to remind you of your appointment or to reschedule an appointment.
We may use disclose your information to assess the care and outcomes or your care and others like it. These results will then be used to continually improve the quality of care for all the patients we serve.
We may send you satisfaction surveys to assess your satisfaction with our services.
We may send you information about health-related services or benefits.
We will disclose your health information to third-party “business associates” that performs various activities such as billing or accreditation on our behalf. Our business associates’ access to your health information will be limited, and we require our business associates to safeguard your information just as we do.

Individuals Involved in Your Care: If you agree, we may release certain health information about you to a friend or family member involved in your care or payment related to your care. If you are unable to agree due to your incapacity or emergency circumstances, we may disclose your health care information necessary if we determine that is in your best interest, based on our professional judgment. We may disclose information about you to an organization assisting in a disaster relief effort so that your family can be notified about your condition, status, and location.

Workers’ Compensation: We may disclose your health information as authorized to comply with workers’ compensation laws and other similar legally established programs.

Other Uses and Disclosures Without Your Authorization

In addition to the above-listed purposes, we may need to use or disclose your health information without your authorization for the following purposes:

To the government for public health activities as permitted or required by law to report disease statistics, births and deaths, child or vulnerable adult abuse or neglect, domestic violence, reactions to medications, problems with products, and disease exposures;
To a health oversight agency for audits, investigations, inspections, accreditation and licensure activities;
To prevent a serious and imminent threat to the health or safety or a person or the public to help the police apprehend an individual involved in a violent crime;
To a law enforcement official in response to a court order to identify or locate a suspect, witness, or missing persons;
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 court or party in litigation in response to a valid court 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 otherwise as necessary to carry out their duties;
If you are an inmate of a correctional institution, to the institution as necessary for your health and the health and safety of other individuals;
For military, national security or lawful intelligence activities; or
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 in writing at any time, but we cannot take back any disclosures we have already made in reliance on your authorization.

Your Rights Regarding Your Health Information

Access to Your Health Information: With some exceptions, you have the right to inspect and request a copy of your medical records, billing records and records used to make decisions about your care or services is those records include health information about you and are maintained or used by us. If you wish to access to your health information, please write to us and we will respond to your request and tell you when and where you can review your health information in our possession within our normal business hours. If you would like a copy of you health information, we may charge a reasonable administrative fee for copying your health information to the extent permitted by applicable law. If we deny your request for review or copy of you health information, we will explain the reason in writing. If your request to review or copy your medical information is denied, you can request in writing that we ask another licensed health care professional within our organization to review your request and the denial. The person conducting the second review will not be the person who denied your original request.

Right to Amend Your Health Information: You have the right to request amendments to your health information if you feel that records are incorrect or incomplete. If you wish to have you health information corrected or updated, please write to us and tell us what you want changed and why. We will respond to you in writing, either accepting or denying your request. If we deny your request, we will explain why.

Right to Receive an Accounting of Disclosures of Your Health Information: You have the right to request an accounting of certain disclosures that we make of your health information. You can request an accounting by writing to us. Certain disclosures, such as those made with your consent and/or for treatment, payment, or healthcare operations, will not be included in the accounting we provide to you. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. The first accounting you request within a 12-month period will be free. For additional accountings, we may charge you for the costs of providing the accounting. We will notify you in advance of the cost involved.

Right to Request Restrictions: You have the right to request restrictions on how we use and disclose your health information for our treatment, payment, and health care operations, we are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide your emergency treatment. To request a restriction you must make your request in writing to:

Compliance Officer

Lake Superior Community Health Center

4325 Grand Ave.

Duluth, MN 55807

In your request, you must tell us (1) what information you want to limit; (2) whether and how you want to limit our use, disclosure or both; and (3) to whom you want to limits to apply.

Right to Confidential Communications: You have the right to request that we provide your health information to you in a confidential manner. For example, you may request that we send your health information by an alternate means (e.g., sending by a sealed envelope, rather than a post card) or to an alternate address (e.g., calling you at a different telephone number, or sending a letter to you at your office address rather than your home address). We will attempt to accommodate any reasonable request, unless they are administratively too burdensome or prohibited by law.

Right to Complain: If you have any questions about this Notice, believe that your privacy rights have been violated, or wish to file a complaint; please direct your inquiries to:

Privacy Officer

Lake Superior Community Health Center

4325 Grand Ave.

Duluth, MN 55807

You may also complete a complaint form while in any of our clinics and it will be forwarded to the Privacy Officer for resolution. You also have the right to directly complain to the Secretary of the United States Department of Health and Human Service. If you wish to do so, please write to the Office for Civil rights at:

U.S. Department of Health and Human Services

233 No. Michigan Avenue., Suite 240

Chicago, IL 60601.

We will not retaliate against you for filing a complaint against us.