THIS NOTICE DESCRIBES HOW PROTECTED MEDICAL INFORMATION ABOUT YOU MAY
BE USED AND DISCLOSED AND HOW YOU CAN GAIN ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
NOTE: INDIVIDUALS WITH COMMUNICATIONS BARRIERS OR WHO SPEAK A LANGUAGE
OTHER THAN ENGLISH WILL BE PROVIDED WITH REASONABLE ACCOMODATION TO
RECEIVE THIS NOTICE IN A FORM THEY CAN UNDERSTAND.
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
d. National Security: If required by law we may reveal information
about you to federal officials involved in national security or federal
e. Other Legal Disclosures: If state or federal law compels Upper
Mississippi Mental Health Center to release information, we will release
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
5. The Individual has the following rights regarding protected health
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
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
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
13. Upper Mississippi Mental Health Center’s contact person for
matters relating to complaints is:
a. Executive Director
c. Upper Mississippi Mental Health Center, PO Box 640, Bemidji, MN
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.
UPPER MISSISSIPPI MENTAL HEALTH CENTER
THIS PAGE TO BE PLACED IN CLIENT RECORD
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
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