Notice of Privacy Practices

This notice describes how health information about you may be used and disclosed and how you can get access to this information.

Please review it carefully.

Our Health Information Duties

We have a legal duty to protect the privacy of your health information and to give you this Notice.
We have a legal duty to abide by the Notice of Privacy Practices that is current.
We may change the terms of this Notice and to make the new terms effective for all health information we have. This includes health information we created or received before we made the changes.
We will make any revised Notice available in hard copy, and by displaying it in our facilities and on our Web site. Also, you can request the revised Notice in-person or by mail.

“Health information” means, generally, information about your past or present health status, condition, diagnosis, treatment, prognosis, or payment for health care.

Who will Follow this Notice

This notice describes our facility’s practices and that of any employee, student, intern, or contracted service provider authorized to enter information into your medical and billing records.

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Your Health Information Rights

Restrictions on Use or Disclosure. This Notice describes some restrictions on how we can use and give out your health information. You may ask us for extra limits on how we use or to whom we give the information. You need to make your request in writing. We are not required to agree to your request. If we do agree, we will follow our agreement, except:

in an emergency where the information is needed for your treatment
if you give us written permission to use or give out your information
if you or we end the restriction, or
as otherwise required by law.

Alternative Communication. Normally, we will communicate with you at the address and phone you give us. You may ask us to communicate with you by other ways or at another location. Your request needs to explain how you want the information communicated and where. We will agree to your request if it is reasonable. If you restrict us from providing information to your insurer, you also need to explain how you will pay for your treatments.

Client Access. You may look at or get copies of your health information. (There are some exceptions.) You need to make your request in writing. If you ask for copies in a format other than paper copies, we will give you that other format if practical. If you ask for copies, we may charge fees as allowed for by law. If you ask for your records in a format we can provide, we will charge a reasonable fee based on our costs. If your request is denied, we will send the denial in writing. This will include the reason and describe any right you may have to a review of the denial.

Amendment. You may ask us to change certain health information. You need to make your request in writing. You must explain why the information should be changed. If we accept your change, we will try to inform others (including people you list in writing) of the change. We will include the changes in future disclosures of your health information. If your request is denied, we will send the denial in writing. This denial will include the reason and describe any steps you may take in response.

Disclosure List. You may receive a free list of disclosures - with some exceptions – made by us or our business associates of your health information. The list does not include:

disclosures made for treatment, payment or health care operations
disclosures made before April 14, 2003
disclosures you have authorized
certain other disclosures.

You need to make your request in writing. If you ask for a list more than once in a 12-month period, we may charge you a fee for each extra list. You may withdraw or change your request to reduce or eliminate the charge.

Paper Copy of Notice. You may receive a paper copy of our current Notice of Privacy Practices.

How to Use These Rights. Please contact us at the Contact Office listed on the last page to use any of these rights or receive more information about any related fees.

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Uses and Disclosures of Health Information

To provide you care, we have certain reasons we use and disclose health information. We make all uses and disclosures according to our privacy policies and the law. We may use and give your health information as follows:

(If you are receiving chemical dependency treatment, not every disclosure identified below will apply.)

Treatment, Payment and Health Care Operations. We may use and give your health information for:

treatment (includes working with another provider)
payment (such as billing for services provided)
our health care operations. These are non-treatment and non-payment activities that let us run our business or provide services. These include, for example, quality assessment and conducting training programs.

We may share health information within the organization as necessary for treatment, payment or health care operations.

Medical Emergency. We may use or give your health information to help you in a medical emergency.

Appointment Reminders; Treatment Alternatives. We may send you appointment reminders, or tell you about treatments and health-related benefits or services that you may find helpful.

Law Enforcement. We may give certain health information to law enforcement. This could be:

when there may have been crime at the facility, or
when there is a serious threat to the health or safety of another person or people.

Correctional Facility. We may give the health information of an inmate or other person in custody to law enforcement or a correctional institution.

Abuse or Neglect. We may give health information to the proper authorities about possible abuse or neglect of a child or a vulnerable adult.

Military Authorities/National Security. We may give health information to authorized people from the U.S. military, foreign military, and U.S. national security or protective services.

Public Health Risks. We may give health information about you for public health purposes. These purposes include the following:

reporting and controlling disease (such as tuberculosis), injury or disability
reporting adverse events related to food, medications, or problems with health products
notifying a person who may have been exposed to a disease or be at risk for catching or spreading a disease or condition.

Health Oversight Activities. We may give health information to government, licensing, auditing and accrediting agencies for actions allowed or required by law.

Required by Other Laws. We may use or give health information as required by other laws. For example:

We may give health information to the U.S. Department of Health and Human Services during an investigation.
We may give health information under workers’ compensation or similar laws. We may give health information:
To social services and other agencies or people allowed to receive information about certain injuries or health conditions for social service, health or law enforcement reasons.
About an emancipated minor or a minor receiving confidential services to prevent a serious threat to the health of the minor.

Legal Process. We may give health information in response to a state or federal court order, legal orders, subpoenas, or other legal documents.

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With Your Authorization

Except for what is listed above, we may use or give health information only with your written permission. If you give written permission, you may revoke it at any time by notifying us in writing. This form is available from the Contact Office listed below. Your permission will end when we receive the signed form, or when we have acted on your request.

Questions and Complaints

If you have questions about our privacy practices, please contact our Privacy Officer at the following address and/or phone number – Chrysalis, 4432 Chicago Avenue South, Minneapolis MN 55407, 612-871-0118. If you think your privacy rights have been violated, or if you disagree with a decision about any of your rights, you may also file a complaint with us at this address.

You also may send a written complaint to the U.S. Department of Health and Human Services. We will give you the address to file a complaint if you ask for it. We will not punish you or retaliate if you choose to file a complaint.

This Notice takes effect April 14, 2003. It will remain in effect until we replace it.

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