Minnesota Notice of Privacy Practices
Your Information. Your Rights. Our Responsibilities.
This document contains important information about federal law, the Health Insurance Portability and Accountability Act (HIPAA), that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations.
HIPAA requires that we provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice explains HIPAA and its application to your PHI in greater detail.
The law requires that we obtain your signature acknowledging that we have provided you with this. If you have any questions, it is your right and obligation to ask so we can have a further discussion prior to signing this document. When you sign this document, it will also represent an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding unless we have taken action in reliance on it.
LIMITS ON CONFIDENTIALITY
There are some situations in which we are legally obligated to take actions, which we believe are necessary to attempt to protect others from harm, and we may have to reveal some information about a patient's treatment:
1. If we know, or have reason to suspect, that a child under 18 has been abused, abandoned, or neglected by a parent, legal custodian, caregiver, or any other person responsible for the child's welfare, the law requires that we file a report to the appropriate common entry point, typically the local office of Social Services or to law enforcement. Once such a report is filed, we may be required to provide additional information.
2. If we know or have reasonable cause to suspect that a vulnerable adult has been abused, neglected, or exploited, the law requires that we file a report with the Minnesota Adult Abuse Reporting Center or the appropriate common entry point. Once such a report is filed, we may be required to provide additional information.
3. If we believe that there is a clear and immediate probability of physical harm to the patient, to other individuals, or to society, we may be required to disclose information to take protective action, including communicating the information to the potential victim, and/or appropriate family member, and/or the police or to seek hospitalization of the patient.
USES AND DISCLOSURES
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.
For Treatment – 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. Furthermore, an authorization is required for most uses and disclosures of psychotherapy notes.
For Payment – 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. Disclosures are outlined in Informed Consent Agreement, Consent for Release of Private Information to Insurer and Assignment of Benefits Form, and Electronic Authorization Consent From.
For Operations – 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.
OTHER DISCLOSURES
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: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Public Health and Safety- 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.
Research- We can use or share your information for health research if you do not object.
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 are complying with federal privacy law.
Organ and Tissue donation- We can share health information about you with organ procurement organizations only with your consent.
Medical Examiner- 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.
Worker’s compensation, law enforcement, government- 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; 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.
Respond to legal action-In most legal proceedings, you have the right to prevent us from providing any information about your treatment. In some legal proceedings, a judge may order my testimony if they determine the issues demand it and we must comply with that court order. There are some situations in which we are legally obligated to take action to protect others from harm, even if that means revealing some information about a patient’s treatment. For example, if we are concerned that a child or vulnerable adult is being abused, we must make a report to the appropriate state agency. Or, if there is threat to bodily harm someone else, we may be required to take protective actions. Finally, if there is concern that a patient may harm themselves, we may be obligated to try to intervene. If any situation like this occurs in our work together, we will attempt to fully discuss it with you before taking any action.
Our providers may seek professional consultation regarding your case with peer counselors in order to provide excellence in the service they provide in accordance with accepted professional behavior. In doing so, your identity or other details regarding your identity will be withheld to maintain confidentiality.
Other state laws- 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.
YOUR RIGHTS
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Right to Inspect and Copy your medical record - You have the right to inspect or obtain a copy (or both) of PHI. We will provide a copy or a summary of your health information within a reasonable time. If you ask to see or receive a copy of your record for purposes of reviewing current medical care, we may not charge you a fee. If you request previous records, you will be charged a fee of $.75 per page. If we refuse your request for access to your records, you have a right of review, which we will discuss with you upon request.
Right to Amend – If you believe the information in your records is incorrect and/or missing important information, you can ask us to make certain changes, also known as amending, to your health information. You have to make this request in writing. You must tell us the reasons you want to make these changes, and we will decide if it is appropriate to do so or, if I refuse to do so, I will tell you why within 60 days.
Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You can ask us 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.
Right to Request Restrictions – You can ask us 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. Minnesota Law requires consent for disclosure of treatment, payment, or operations information.
Right to an Accounting – You can ask 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). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Right to a Copy of This Notice – You can ask for 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- You can complain if you feel we have violated your rights by contacting us or the U.S. Department of Health and Human Services Office for Civil Rights. We will not retaliate against you for filing a complaint. Complaints must be in writing and contact information can be found under the “COMPLAINTS” section of this document.
Right to Treatment – You have the right to ethical treatment without discrimination regarding race, ethnicity, gender identity, sexual orientation, religion, disability status, age, or any other protected category.
Right to Choose Someone to Act for You – If someone is your legal guardian, that person can exercise your rights and make choices about your health information; we will make sure the person has this authority and can act for you before we take any action.
Right to Terminate – You have the right to terminate therapeutic services with us at any time without any legal or financial obligations other than those already accrued. We ask that you discuss your decision with us in session before terminating or at least contact Us by phone letting us know you are terminating services.
Right to Release Information with Written Consent – With your written consent, any part of your record can be released to any person or agency you designate. Together, we will discuss whether or not we think releasing the information in question to that person or agency might be harmful to you. Components of your health record including information regarding chemical health records and HIV/AIDS are protected under Title 42 (Code of Federal Rules of Privacy of Individually Identifiable Health Information, Parts 160 and 164) and Title 45 (Federal Rules of Confidentiality of Alcohol and Drug Abuse Patient Records, Chapter 1, Part 2), plus applicable state laws. Records regarding these specific topics cannot be released unless specifically authorized by you on the Authorization of Release of Information Form.
YOUR CHOICES
Fundraising- We may contact you for fundraising efforts, but you can tell us not to contact you again.
Request 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:
1. Share information with your family, close friends, or others involved in your care.
2. 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- For purposes of marketing, sale of your information, and most sharing of psychotherapy notes we will never share your information unless you give us written permission. Minnesota law requires consent for most other sharing purposes.
OUR RESPONSIBILITIES
Maintain Privacy & Security- We are required by law to maintain the privacy and security of your protected health information.
Inform of a 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 in writing.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html
COMPLAINTS
If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact us, the State of Minnesota Department of Health, or the Secretary of the U.S. Department of Health and Human Services in writing to file a formal complaint.
Strong Self Mental Health PLLP
Privacy Official: Thea Rothman Ph.D., LP
116 E Lincoln Ave
Fergus Falls, MN 56537
Phone: 218-382-5380
hello@strongself116.com
U.S. Department of Health and Human Services
Office for Civil Rights
200 Independence Ave S.W.
Washington D.C. 20201
Phone 1-877- 696-6775
https://www.hhs.gov/hipaa/filing-a-complaint/index.html
EFFECTIVE DATE AND CHANGES TO THIS NOTICE
Effective Date: This Notice is effective on 1/2/2023.
Changes to this Notice- We may change the terms of this Notice at any time. If we change this Notice, we may make the new notice terms effective for all PHI that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, the new notice will be available upon request, in our office, and on your client portal website.
COVERED ENTITIES
Strong Self Mental Health PLLP
Privacy Official: Thea Rothmann Ph.D., LP
116 East Lincoln Avenue
Fergus Falls, MN 56537
218-382-5380
hello@strongself116.com
Langfeld Counseling PLLC
Privacy Official: Hillary Langfeld, LICSW
116 East Lincoln Avenue
Fergus Falls, MN 56537
Phone: 218-203-0447
hillary@strongself116.com
Thea Rothmann, PhD, LP, PLLC
Privacy Official: Thea Rothmann Ph.D., LP
116 East Lincoln Avenue
Fergus Falls, MN
Phone: Phone: 218-332-0830
thea@strongself116.com
Erin Swenson, LICSW PLLC
Privacy Official: Erin Swenson, LICSW
116 East Lincoln Avenue
Fergus Falls, MN 56537
Phone: 218-332-0780
erin@strongself116.com
Next Right Thing Mental Health and Recovery Services, PLLC
Privacy Official: Michelle Wilson, LPCC, LADC
116 East Lincoln Ave
Fergus Falls MN, 56537
Phone: (218) 332-0288
michelle@strongself116.com
Balance Mental Health, PLLC
Privacy Official: Abbey Kwapinski, LPCC
116 East Lincoln Ave
Fergus Falls, MN 56537
Phone:(218) 332-0434
abbey@strongself116.com