Your Information, Your Rights, Our Responsibilities

Notice of Privacy Practices: Effective date July 7, 2020

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

This Notice of Privacy Practices applies to Southdale Anesthesiologists, LLC. (referred to in this Notice as “we,” “our” or “us”). We partner to provide care and related services to patients at multiple different locations.

We understand that medical information about you is personal and private. We keep a record of the care and services you receive in order to provide you with quality care and to meet legal requirements.

Your health information

In this Notice, the phrase “your health information” or “your information” refers to records that we keep related to your health care. The record may include health information like a diagnosis, a treatment plan, visit notes, test results or payment for those services. It also includes information such as your name, address, phone number and date of birth.

YOUR RIGHTS

This section explains your rights over your health information. If you have a request, we may ask you to submit it in writing. You may ask at one of our care locations how to do this.

You have a right to:

Get a copy of your medical record

• You can ask to see or copy an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
• We will send a copy or a summary as soon as possible. This may take up to 30 days, and we may charge a fee as permitted under state law.

Ask us to correct or amend your medical record

• You can ask us in writing to correct health information that you think is wrong or missing. Ask us how to do this.
• We may say “no” to your request, but we will tell you why as soon as possible, usually within 60 days.

Ask for private communications

• You can tell us how you would like to be contacted (for example, home, mobile or office phone) or to send mail to a different address.
• We will do our best to honor all requests within reason.

Ask us to limit what we use or share

• You can ask us not to use or share your health information. We will always consider your request, but we are not required to agree to it. We may say “no” if it would affect your care or we cannot do it.
• If you pay for a service or health care item in full, out-of-pocket, you can ask us not to share that fact with your health insurer when you check in or register. We will honor your request unless a law requires us to share that information with the health plan.

Get a list of who has your information

• You can ask for a list (an “accounting”) of the times we have shared your health information with an outside organization or person. It will show who we shared it with and why.
• The list may go back as long as six years from the date you ask.
• We would not include the times your information was shared for treatment, payment, or business and other times (such as when you asked us to share information).
• You may receive one report per year at no cost. If you ask for another one within 12 months, we will charge a fee.

Get a copy of this Notice

• You can ask for a paper copy of this Notice at any time. We will send the Notice right away, even if you have agreed to receive it by email in the past.
• This Notice is also on our websites.

Choose someone to act for you

• You may have given someone medical power of attorney or you may have a legal guardian. They can exercise your rights and make choices about your health information.
• We will make sure that the person you chose has this authority and can act for you before we take any action.

File a complaint

• You may file a complaint with us if you feel we have violated your privacy rights. Contact us using the information on the last page of this Notice.
• You may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights via e-mail at OCRMail@hhs.gov, by phone at 1-800-368-1019 (TDD: 1-800-537-7697), by U.S. mail at 200 Independence Avenue, S.W., Room 509F HHH Bldg., Washington, D.C. 20201, or by visiting:

           www.hhs.gov/ocr/privacy/hipaa/complaints/

• We will not penalize you or act against you in any way for filing a complaint.

YOUR CHOICES

You have choices about how we use and share your health information. Let us know what you want us to do, and we will follow your instructions as best we can.

You may tell us NOT to:

• Share your information with your family, close friends or others involved in your care.
• Include your information in a patient directory that can be used to locate you.
• Share your information in a disaster relief situation.
• Contact you to raise money to support our mission.

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.

We need your written permission before:

• We use or share your information for marketing purposes;
• We sell your information;
• We share psychotherapy notes if they were kept for services you have received; or
• We share substance use disorder treatment program records.

Minnesota Law also requires consent for most other sharing purposes.

OUR USES AND DISCLOSURES

How do we use your health information?

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.

To treat you (treatment)

We use and share your health information to treat you and coordinate your care. When you first become a patient, we ask for your written permission to share your information with health care providers caring for you outside of our facilities. In an emergency, we may have to share your information without your consent.

     Example: A doctor treating you for an injury asks another doctor about your overall health.

     Example: We use and share your information to remind you of an appointment with us.

To run our organization (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.

     Example: We use some of your health information to evaluate our services; review and train students, staff and care providers; and assess new treatments.

     Example: We share some information with our business partners – those we work with to provide operational services, but who are not our employees or affiliates. The law requires our business partners to safeguard your information the same way we do.

To bill for your services (payment)

We use and share your health information to bill and get payment from health plans and others for care that you receive. When you first become a patient, we will ask you for your written consent to share your information for this purpose.

     Example: We give information to your health insurer about the services we gave you so they will pay for those services.

     Example: We share information with our accountable care organizations or networks to coordinate, manage costs and generate value for your care.

How else can we use or share your health information?

We may share your information in other ways:

For public health and safety

We can share your information with public health or other authorized agencies in order to:

• Prevent or control diseases;
• Help with product recalls;
• Report bad reactions to medicines;
• Report births and deaths;
• Report suspected abuse or neglect of a child or vulnerable adult;
• Prevent or reduce a serious threat to anyone’s health or safety;
• Help with health system oversight activities, such as audits, inspections, or investigations; or
• Comply with government functions such as military, national security, correctional facilities, and presidential protective services.

For research

We may ask to use or share your information for health research. In order to use your information:

      --We must meet the conditions of both state and federal law.

      --We must get approval from you or a research board.

When you first become a patient, we will ask you whether you wish to have your information used for research. You may choose not to allow use of your information in research. Contact us at the phone numbers or addresses listed at the end of this Notice.

To inform about our services

We can use and share your information to tell you about treatment options and health-related services that may interest you.

To contact you by phone or electronic communication

We use telephone, email, and text message tools to communicate with you about information related to your care such as appointment reminders and satisfaction surveys. You can update your communication preferences at any time.

For fundraising

We can use and share limited information to contact you about donating to our activities.

You can tell us not to contact you again by following the “opt-out” instructions given in printed fundraising requests. Or you can contact us at any of the phone numbers or addresses listed at the end of this Notice.

For organ and tissue donation

We can share your health information to help with organ or tissue donation.

To work with a medical examiner or coroner

We can share your health information with a coroner, medical examiner or funeral director.

To handle workers’ compensation claims

We can share your information for your claims for workers’ compensation and similar programs for work-related injuries or illness.

To respond to lawsuits and legal actions

We can share your information for legal actions such as a court order, grand jury subpoena, warrant or other legal process. We can share your information with law enforcement officials as required by law.

To comply with the law

We can share your information if state or federal laws require it. In Minnesota, 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.

GDPR notice for European citizens

We comply with United States federal and state laws regarding the privacy of your health information. If you are located in the European Union, you may withdraw your consent to our use of any personally identifying information previously provided at any time by contacting us in writing.

Privacy rights of minors

In some cases, such as when seeking treatment for substance use disorder or sexually transmitted diseases, persons under age 18 may consent to treatment and make decisions about the release of their protected health information without parental or guardian consent.

OUR RESPONSIBILITIES

• We are required by law to keep your health information private and secure.
• We will tell you if there has been a breach of your health information.
• 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 except as described in this Notice unless you give us written permission. You may change your mind at any time by letting us know in writing.
• We cannot take back any information we have already shared with your permission.

For more information see:

www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html

Changes to the terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request and on our website.

For information or concerns

You may contact us for any questions about this Notice or concerns about the privacy of your patient information or to inform us of your choices.

Southdale Anesthesiologists, LLC

Gregory Maurer, HIPAA Officer

9368 Redwell Lane

Woodbury, MN 55125

Email: gmaurer@sallcmn.com

Phone: 612-850-0035