Privacy Practices Notice
Effective February 25, 2011

This notice applies to all Protected Health Information (PHI) maintained at Wyndgate Health PLLC. We are committed to respecting your privacy and to limiting disclosures of PHI to those permitted by law or specifically authorized by you. We will abide by the terms of this notice and notify you in writing in a timely manner if we cannot agree to a requested restriction.

This notice may be revised. In the event that we revise this Notice of Privacy Practices, we will make the revised version available to you in hard copy, by displaying it in common areas of our agency, and on our website at www.wyndgatehealth.com. You may request a current copy of this notice at any time in person or by mail. We will abide by the current Notice of Privacy Practices for information that is current or created prior to the date of the revision.

Wyndgate Health will use and disclose PHI for the following purposes:

For Treatment: We may use your private health information about you to provide treatment or services. For example, we may disclose information about you to therapists or other personnel who are directly involved in providing care or services to you at Wyndgate Health PLLC.

For Payment: We may use and disclose information about your treatment and services to bill and collect payment from you or a third party payer. For example, we may provide your information about the services you/your child receives so that they will reimburse you for the services provided. We may also tell your health plan about treatment or services you are going to receive.

For Health Care Operations: Members of our staff may use information in your client file to assess the care you receive and outcomes in your case and others like it. The results will then be used to continually improve the quality of care for all clients we serve. For example, we may combine information about many clients to evaluate the need for new services or treatment. We may also use and disclose private health information for the following purposes:

• To remind you that you have an appointment for services;
• To assess your satisfaction with our services;
• To communicate with you via newsletters, mailings or other means regarding treatment options, seminars, or other initiatives or activities in which Wyndgate Health is participating;
• For law enforcement purposes as required by law or in response to a valid subpoena;
• To business associates with whom we may have contracted to perform agreed upon services and the related billing for those services.

Required Disclosures Permitted Without Your Authorization: State and federal laws allow for some situations in which your health information may be disclosed without your consent. Some situations include:

• For reporting of suspected abuse or neglect of a child, maltreatment of a vulnerable adult, and in the event that a client is at risk of harm to him/herself or another;
• For health oversight activities authorized by law including audits, investigations, inspections, licensure or disciplinary actions;
• For judicial and administrative proceedings in response to an order, subpoena, discovery request or other lawful process;
• For specific law enforcement purposes including responding to a warrant or subpoena;
• When coroners and medical examiners require information about a decedent;
• For certain specialized government functions related to national security and the military;
• For purposes of conducting research, provided that certain privacy protections are followed;

Refer to http://www.health.state.mn.us/divs/hpsc/dap/notice.pdf for more detailed information about other situations.

Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose health information, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission and that we are required to retain our records of the care that we provided to you.

Although your health record is the physical property of the facility that compiled it, State and federal laws ensure that you have the right to access and control your private health information. Details about these rights are provided below:

Inspect and Copy: You have the right to inspect and obtain a copy of any of your health information unless that information is judged harmful to your physical or mental health or is likely to cause you to harm yourself or others. You may be charged a fee for this copy.

Correct (amend) Your Health Information: If you feel that private health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for Wyndgate Health PLLC. To make such a request, complete the Request to Amend Records form and return it to the Privacy Official at Wyndgate Health PLLC. Please include with this form any documentation you have that will assist us in the review of your request. Those involved in your care and senior staff will review the request. Although we reserve the right to disagree with your request, we will take appropriate action to correct any inaccurate information in a timely manner through established policies and procedures. You will be notified in writing when the amendment is completed.

Request Confidential Communications: You have the right to request that we communicate with you about private matters in a certain way or at a certain location. We will agree to the request to the extent that it is reasonable for us to do so. For example, you can ask that we use an alternate phone number to contact you regarding your services.

An Accounting of Disclosures: You have the right to request an accounting of disclosures. This is a list of all the disclosures we make of health information about you or your child that are not specifically authorized by law or by the client or guardian of the client.

Request Restrictions: You have the right to request restrictions or limitations on the health information we use or disclose about you for treatment, research, payment or heath care operations. Generally, we are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide emergency treatment. Beginning February 17, 2011, we must comply with a requested restriction if the disclosure is to a health plan for purposes of payment or health care operations and the health information relates to a health care item or service for which an individual paid in full out-of-pocket. For example, if you receive medical care and choose to pay us for the entire amount of care in full out-of-pocket, you can request that we not disclose such information to your health plan and we must agree to such a request.

A Paper Copy of this Notice: You have the right to a paper copy of this notice. You may request one at any time. You can also access this notice on our website www.wyndgatehealth.com.

Changes to this Notice: We reserve the right to change this notice and the revised or changed notice will be effective for information we have about you as well as any information we receive in the future. The current notice will be posted in a conspicuous location in our facility and include the effective date.

Complaints: If you believe your privacy rights have been violated, you may file a complaint with Wyndgate Health PLLC by contacting us via the below number and asking for our Privacy Official, or you may file a complaint with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing.

You will not be penalized for making a complaint. To exercise any of your rights outlined above, please ask for the applicable form from the Wyndgate Health PLLC employee providing care to you or your child or from the Privacy Official and submit your request in writing.