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Upper Mississippi Mental Health Center
Notice of Privacy Practices



1. Upper Mississippi Mental Health Center is permitted to make uses and disclosures of protected health information for treatment, payment and health care operations, as described in the following examples:

a. For treatment – We may use information about you in order to provide treatment or services. We may disclose or share information about you to any of the staff the Mental Health Center involved with your care. Different programs at the Mental Health Center may need to share information about you in order to coordinate the care you receive. For instance, a psychiatrist may share information about medications you are taking with your therapist, or your case manager may alert your psychiatrist about side effects you are experiencing.
b. For payment – We may use information about you to help obtain payment for services rendered to you. This information may be shared internally between staff such as the Reception staff telling your therapist that your insurance plan provides for ten visits or your therapist telling the billing staff your diagnosis in order to include this on the billing form. We also will share information with insurance companies if you authorize your insurance company to be billed such as our providing a diagnosis or a list of the specific services you have received in order to obtain payment.
c. For health care operations – We may use information about you with our staff in order to help coordinate your care or to direct our staff and make sure supplies and other resources are available. For instance, we may review your records to monitor our quality of care and our documentation of your care; we may involve support staff in your care to type clinical records or to schedule your services; we may use your case as a discussion point in clinical meetings where cases are reviewed and discussed.

2. Besides the uses described for treatment, payment and operations, Upper Mississippi Mental Health Center is permitted or required, under specific circumstances, to use or disclose an individual’s protected health information at other times without the individual’s written authorization. Some examples of these circumstances are:

a. Health Oversight Activities: We may disclose information to a government group to allow them to monitor the health care system. Examples would be licensure surveys, audits, investigations, inspections and compliance with civil rights.
b. Lawsuits and Law Enforcement Requests: If you are involved in a lawsuit, we may disclose information about you in response to a court order. If we are presented with a court order we will provide information to law enforcement about you.
c. Protection of Vulnerable Persons: We may reveal information about you if there is a necessity to report abuse of a child or a vulnerable adult.
d. National Security: If required by law we may reveal information about you to federal officials involved in national security or federal protective services.
e. Other Legal Disclosures: If state or federal law compels Upper Mississippi Mental Health Center to release information, we will release it.

3. Other uses and disclosures will be made only with the Individual's written authorization, and the individual may revoke such authorization. Written authorizations will be valid for one year, after which time they will need to be renewed if they are to continue. This is true even for individual’s who die, their written authorizations continue only to end of the year they were in effect.

4. Upper Mississippi may contact individual clients to provide appointment reminders or information about treatment or alternative treatments or other health related benefits and services that may be of interest to the individual.

5. The Individual has the following rights regarding protected health information:

a. The right to request restrictions on certain uses and disclosures of protected health information. Upper Mississippi Mental Health Center is not required to agree to a requested restriction, however.
b. The right to receive confidential communications of protected health information, as applicable.
c. The right to inspect and copy protected health information, as provided in the Privacy Regulation.
d. The right to amend protected health information, as provided in the Privacy Regulation.
e. The right to receive an accounting of disclosures of protected health information.
f. The right to obtain a paper copy of this Notice from the covered entity upon request. This right extends to an individual who has agreed to receive the Notice electronically.

6. Upper Mississippi Mental Health Center is required by law to maintain the privacy of protected health information and to provide individuals with notice of its legal duties and privacy practices with respect to protected health information. This Notice of Privacy Practices fulfills this purpose.

7. Upper Mississippi Mental Health Center will provide all new clients with a copy of this Notice of Privacy Practices when they are completing the registration process before their first service. This may be delayed in instances where individuals are so upset that this would be impractical or unsafe. In these instances, as soon as the individual is calmer, this Notice will be given.

8. Upper Mississippi Mental Health Center is required to abide by the terms of the Notice currently in effect.

9. Upper Mississippi Mental Health Center reserves the right to change the terms of this Notice. Upper Mississippi Mental Health Center reserves the right to make new Notice provisions effective for all protected health information that it maintains or to apply it only to new information obtained or created after the date of the change in the Notice.

10. Upper Mississippi Mental Health Center will provide individuals or clients with a revised Notice by posting the new Notice in the lobby of its offices. Any person may ask for a copy of the new Notice.

11. Upper Mississippi Mental Health Center will provide written copies of this notice and will have electronic versions available on Microsoft Word for email. Also, if the Mental Health Center develops a web-page it will include the Notice in the material included in the web-site.

12. Individuals may complain to Upper Mississippi Mental Health Center and to the Secretary of the Department of Health and Human Services, without fear of retaliation by the organization, if they believe their privacy rights have been violated. A brief description of how the individual may file a complaint follows:

a. Make your complaint known to agency staff involved with your care or in the reception area and ask for a remedy.
b. If you are unsatisfied with the resolution of your complaint, ask to have a form to put your complaint into writing (staff may assist you if you are unable to do this yourself).
c. Your complaint will be logged and then directed to the Clinical Director or the Executive Director.
d. If you are afraid to address your complaint to persons involved in your care then do not do so; instead ask the reception staff for a complaint form. You are not required to address the persons involved with your care regarding your complaint unless you are comfortable doing so.

13. Upper Mississippi Mental Health Center’s contact person for matters relating to complaints is:

a. Executive Director
b. 218/751-3280
c. Upper Mississippi Mental Health Center, PO Box 640, Bemidji, MN 56619-0640

14. This Notice is first in effect on April 14, 2003.

15. Upper Mississippi Mental Health Center elects to limit the uses or disclosures that it is permitted to make, as follows:

Other uses and disclosures of information not covered in this Notice or the laws that apply to its use will be made only with your written permission. If you provide us permission to use or disclose information you may revoke that permission, in writing, at any time. If you revoke your permission, we may not use the information in the way that way previously covered in the authorization.



I. Receipt of Required Notices:

I hereby acknowledge that I have received a copy of Upper Mississippi Mental Health Center’s Notice of Privacy Practices and a copy of Your Rights to Equal Access, Quality Treatment and Privacy.

II. Consent for Treatment and Use of Personal Health Information (PHI):

I acknowledge that I have consented to receive mental health and related services from staff of Upper Mississippi Mental Health Center which will be described in full through the treatment planning process. I understand that I must consent to receive services or I will not be served. I further acknowledge that I consent that my PHI may be used for treatment, payment or operations, subject to the uses and limitations set forth in state and federal law. Any additional uses of my PHI beyond those which are provided for in state and federal law shall require my authorization.

Individual’s Name

Date: ______________________

I certify that the required documents were in fact provided to the individual and/or that verbal consent was received but the client was not able to sign this document at this time due to physical limitations, emotional crisis or other limiting factor.






UMMHC Staff Member

Date: _______________________