HIPAA Client Privacy Practices Signature Form

HIPAA Notice of Client Privacy Practices-form
effective January 1, 2011

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.  If you have questions or comments regarding this notice please contact  at the address below or telephone number. All requests, notifications, and complaints should  be  submitted to: 

Ibrahim Abu-Munye, Oasis President
P: 6513306048 EM: Iabumunye@eahsmn.org
Hennepin Square, Suite 130
2021 E. Hennepin Ave
Minneapolis, MN 55413

Who Does this Notice Apply to?

This notice has been published by Oasis. It applies to everyone  who  works  for Oasis Child and Family Services,  including  all of our employees, contractors, student interns and administrators.

Why Do We Publish this Notice?

As health care professionals, we understand that information about you and your health is sensitive and personal. We are also required by law to maintain the privacy of information that we gather and use about you and all of the clients we serve, and to provide you with notices of our legal duties and privacy practices with respect to your information.

We are committed to the privacy of our clients’ information. However, in order to serve you we need to obtain, secure and utilize records of this information. We occasionally need to share information with other healthcare providers. This notice is intended to inform you how we use and disclose information about you.

This notice is also to inform you about certain legal rights you have with respect to the information we secure about you. You have the right to review and/or receive a copy of your records of information.  You may also request that we amend these records and ask us to account for certain disclosures we may have made of information about you.

When Does This Notice Become Effective?

We are required to comply with the terms of this notice while it is in effect. We reserve the right to change the terms of this notice and make the new terms effective for all information to which this notice applies. This notice went into effect on January 1, 2011, until the date we publish an amended notice. If we do publish an amended notice, we will notify you of the amendment at your next  appointment  through Oasis.   A copy may  be  requested  by  contacting  us  at the above-mentioned telephone number or address.                                      

What Information Does This Notice Cover?

This notice covers all information in our written or electronic records which concerns you, your healthcare, and payment for your healthcare.

Uses and Disclosures of Protected Health Information. How we may use and disclose medical information about you:

We can use or disclose information about you for the following purposes:

  1. Treatment We may use or disclose information about you for treatment purposes to doctors, counselors, therapists, or other individuals who work in our programs who are involved in providing your healthcare.  For example, we may wish to review the quality of care you receive in order to help us deliver the best care we can. Or, we may review our management practices so we can become more efficient. These are only examples, and we may use or disclose information about you for healthcare operations in other ways.
  2. Health Care Operations. We may use or disclose information about you in connection with the operation of our practice. These activities may include practice quality improvement, training of graduate students, insurance underwriting, medical or legal review, and business planning or administration of our practice.  For example, to deliver quality care to you, we may wish to review the quality of care you receive. Or, we may audit our management practices so we can become more efficient. These are only examples, and we may use or disclose information about you for healthcare operations in many other ways.

Without Your Written Consent:

We may only disclose information about you without your consent for the following purposes:

  1. It is determined you are a threat to yourself or another person.
  2. In the event of suspected child abuse, to the appropriate governmental departments.
  3. In other cases of suspected abuse, neglect or domestic violence, to the appropriate governmental authority, with your agreement or if required by law, or if you are incapacitated or it appears necessary to prevent serious harm to you or others.
  4. In litigation, subject to certain requirements controlling the terms of the disclosure.
  5. For psychological research purposes, subject to your authorization or approval by an institutional review board.
  6. There is a medical emergency.

Reminders, Marketing and Research:

We may send you information to support your healthcare, including appointment reminders, information about alternative treatments, health related services which may be of interest to you and, follow-up surveys. Please advise us if you do not wish to receive such communications and we will not use or disclose your information for such purposes. If you wish not to receive this kind of communication, you must advise us in writing or contact the address mentioned above.

We may not use or disclose information about you for any other purpose without your written authorization, providing separately from your written consent.

What Legal Rights Do You Have in Connection to Your Health Information?

By law, you are entitled to:  

Request a Restriction  Ask us to further restrict our use and disclosure of information about you. We are not required to grant such as request, but if we do, we must be clear on the restrictions that are implemented.

Confidential Communications  Receive confidential communication from us, at an alternative address until you provide that information to us.

Request a Summary of Your Care  You may receive from your counselor/LADC/Mental Health Professional/Service staff a summary of your counseling starts and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.

Right to Obtain Accounting of Disclosures  Obtain an accounting of all persons to which we have disclosed information about you, for any purpose except your treatment or our healthcare operations.

Right to Revoke Consent for Treatment and Health Care Operations

If you have provided us with an authorization for any purpose, you may revoke it at any time. You may revoke an authorization by giving us written notice at our contact address mentioned above. Your revocation will be effective as of the time we receive it and will not apply to any uses or disclosures which occur before we have received such a request.

Right to Revoke Consent  You may revoke your consent to uses and disclosures for treatment and healthcare operations purposes at any time. You may revoke your consent by giving us a written notice at our contact address mentioned above. Your revocation will be effective as of the time we receive it and will not apply to any uses or disclosures which occur before we have received your request. If you revoke your consent, we may elect to discontinue your healthcare treatment.

Right to File a Complaint  If you believe we have violated your privacy rights, you may forward us a written complaint to our contact address mentioned above. You may also file a complaint with the Secretary of the United States Department of Health and Human Services. If you do file a complaint, we are legally prohibited from retaliating against you.

Complaints cam be submitted to:

Region VIII

Office for Civil Rights
U.S. Dept of Health & Human Services
1961 Stout Street, Room 1185 FOB
Denver, CO 80294-3538

Phone: (303) 844-2025
Fax: (303) 844-2025

TDD: (303) 844-3439

Confidentiality

As a matter of professional ethics and legal requirements, all communications between you and our health care staff are confidential. No information about you will be released outside Oasis Child and Family Services without your written permission. The EXCEPTIONS to this are listed under Without Your Written Permission.  In  the  event  of  such  a  situation, Oasis will make every effort to discuss it with  you prior to taking any action.  Oasis staff finds it helpful to consult with other professionals to better serve you.  During consultation, the identity of clients is concealed,  and confidentiality is maintained.  In addition, Oasis keeps a record of your visits.  This record contains all the  information  you  completed  prior  to   your   intake   appointment,  notes summarizing your sessions, any  psychological test data,  and  other  information  you  may  provide  for us. The records are kept in locked  files  and  maintained  for seven years  following your last  visit. If you have any questions regarding consultation or records, please ask your Oasis Child and Family Services health care staff.