NOTICE OF MEDICAL INFORMATION & PRIVACY RIGHTS

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

During your treatment at Stellis Health, doctors, nurses and other caregivers may gather information about your medical history and your current health. This notice will explain how such information may be used and shared with others. It will also explain your privacy rights regarding this kind of information.

Your medical information will be used and disclosed for the following purposes:

Treatment: We will 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.

Payment: We will use your information to receive payment for the services we provide. For example, we will disclose information to submit bills or claims to insurance companies and/or Medicare or Medicaid.

Health Care Operations: We will use your information for certain activities related to the functioning of the clinic. For example, we may use or disclose information for quality assurance activities, legal services, underwriting, and other business management and administrative activities.

Appointment Reminders and Other Health Information: We 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.

Family Members: We may disclose information to people who will be taking care of you or helping to pay your medical bills, such as family members or other designated caregivers. We will only disclose medical information that these people need to know. We may also use your medical information to let family members or other designated caregivers know where you are and what your general medical condition is. If you can make your own health care decisions, we will ask your permission before using your medical information for these purposes. If you are not able to make your own health care decisions, we will disclose relevant medical information to family members or other designated caregivers if we feel it is in your best interest to do so. For example, we may provide limited medical information to allow a family member to pick up a prescription or X-ray for you.

Emergency Conditions: Under emergency conditions, we may disclose information about you to the government or other groups that assist in emergencies or disasters.

Research: We will not use or disclose any health information that can be used to identify you for research purposes without first obtaining your written authorization or following state law procedures for trying to notify you. At the time of your first visit, you will be given the option to agree or object to the release of your records for research purposes. This release can be revoked or limited in writing at any time by notifying Stellis Health.

Other Uses or Disclosures: We also may disclose or use your information without your consent in the following cases:

when required by law;
for public health activities;

• relating to victims of abuse, neglect, domestic violence, if required/authorized by law and /or if you agree;
• for health oversight activities;
• for judicial and administrative proceedings to the extent permitted by law;
• for law enforcement purposes, as permitted or required by law;
• for research purposes under certain circumstances;
• to avert a serious threat to health or safety;
• certain specialized government functions, such as military discharge, and national security and intelligence;
• for workers’ compensation purposes. Stellis Health will not use or disclose your medical information in any other way unless you allow us to do so in writing. If you do not give us permission to use or disclose your medical information for another purpose, you have the right to change your mind and revoke the permission at any time.
  

  Your Privacy Rights

  Restrict Use and Disclosure: You may request that Stellis Health not use medical information in certain ways or for certain purposes. You may also request that Stellis Health not provide medical information to certain people. However, Stellis Health has the right to refuse your request. Stellis Health may use or disclose the patient’s medical information insituations requiring emergency treatment, in which case we will ask the entities who receive the information not to further use or disclose the information.

  Provide Confidentiality: You may request that Stellis Health provide you with your medical information in a confidential manner. For example, you can request that we send 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 telephone call. You must make this request in writing and specify another address or means of communication. We must agree to your written request. We may also ask you to give us information on how you will pay bills.

  Inspection and Copy: You may ask to see and copy your medical records unless that information is protected by law. You must make these requests in writing. If your request to look at or copy your medical records is denied, you have the right to have the denial reviewed by a health care professional. We will act upon your request within 30 days and may charge you a legally acceptable amount for copying costs.

  Change Information or Amend Medical Records: You may ask us to change information in your medical records. If your request is denied, you can write a statement of disagreement with the denial that we will keep with your medical information.

  Accounting of Disclosures: You may ask us to provide you with information about certain disclosures of your medical information we made in the past. Requests for accounts can go back no more than 6 years from the date request is submitted.

  Privacy Violations: If you feel your medical information privacy rights have been violated, you may file a complaint with the clinic contact person listed below. Filing a complaint will not affect the quality of the services you receive from Stellis Health and you will not be retaliated against for filing a complaint.

  Restriction Requests: You have the right to request that we place restrictions on our use or disclosure of your health information for treatment, payment, or health care operations. We may not be able to agree to all requests for restriction, but if we do, we will abide by our agreement (except in an emergency). Unless we are required by law to submit claims for services to your health plan, we will agree to restrict disclosures to your health plan for payment or health care operations if you pay in full at the time of service.

You may contact the designated privacy official at Stellis Health:

Brent Wilde, CEO Stellis Health, PA
1700 Highway 25 North Buffalo, MN 55313 (763) 682-1313

CHANGES TO THIS NOTICE

The effective date of this notice is April 14, 2003. Stellis Health is 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. Stellis Health is required to abide by the terms of the notice currently in effect. Stellis Health reserves the right to change the terms of this notice and to make new notice information maintained by Stellis Health. If the terms of the notice are changed, Stellis Health will provide individuals with a revised notice upon request and the notice will be available in the reception areas.

Stellis Health, P.A.

Stellis Health – Buffalo Clinic
Stellis Health – Monticello Clinic
Stellis Health – Medical Skin Care Center Stellis Health – Buffalo Urgent Care
Stellis Health – Monticello Urgent Care