Note: This notice describes how healthcare information about you may be used and disclosed and how you can get access to this information. Please read it carefully.

This notice is effective April 24, 2003.

If you have any questions about this notice, please contact: Privacy Officer @ 320-763-1140.

Each time you receive services from a healthcare provider a record of your visit is generated. Typically this record contains your symptoms, examination, test results, diagnosis, treatment, and a plan for future care or treatment. This information is often referred to as your health or medical record and serves as a:

• basis for planning your care and treatment. We use the information to monitor the quality of care that you receive and to make on-going plans for treatment.
• means of communication among the many health professionals who contribute to your care.
• legal document describing the care you receive.
• means by which you or a third party payer can verify that services billed were actually provided.
• tool in educating healthcare professionals for medical research.
• source of information for public health officials responsible for improving the health of the United States.
• source of information for internal business management, planning and development.
• tool to assess and continually work to improve the care we render and the outcomes we achieve.

Understanding what is in your record and how your health information is used helps you to:

• ensure its accuracy by providing us with information about your health.
• better understand who, what, when, where, and why others may access your health information and make more informed decisions when authorizing disclosures to others .
• request communication of your health information by alternative means or at alternative locations.
• revoke your authorization to revoke or disclose health information except to the extent that action has already been taken.

Our responsibilities:

Knute Nelson is required to:

• maintain the privacy of your health information. We must make sure that medical information that identifies you is kept private.
• provide you with this notice of our legal duties and privacy practice with respect to medical information we collect and maintain about you.
• follow the terms of this notice.
• notify you if we are unable to agree with a requested restriction.
• accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.

How we may use or disclose Protected Health Information about you for Treatment, Payment or Health Care Operations:

1) We will use your Protected Health Information for treatment purposes; for example:

Information obtained by a nurse, physician or other member of our healthcare team will be recorded in your record and used to determine the course of treatment that should work best for you. Your physician will document in your record his/her orders for treatment and medications. Members of our healthcare team will then record the actions they take and their observations. In that way, the physician will know how you are responding to treatment.

We may disclose your information to facility and non-facility staff, such as physicians, nurses, nurse aides, technicians, clergy, and medical students who are involved in taking care of you while you are at our facility. We may also disclose information about you to individuals who will be involved in your care after you leave the facility. Unless you object, this may include family members, your physician or a subsequent healthcare provider.

2) We will use your Protected Health Information for payment; for example:

We may use and disclose your medical information to bill and receive payment for the treatment and service you receive during your stay at our facility. For these purposes we may disclose information to your representative, an insurance or managed care company, Medicare, Medicaid or other third party payer. We may inform a health plan about the services you are going to receive to obtain prior approval or to decide if your plan will cover the service.

3) We will use your Protected Health Information for regular health operations; for example:

We may use or disclose your Protected Health Information necessary to manage the facility and to monitor our quality of care to our residents. For example: we may use your Protected Health Information to review our treatment and services to residents which reflects our staff’s performance in caring for you.

Appointment Reminders: We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care at our facility or another facility.

Business Associates: There are some services provided in our organization through contracts with business associates. An example includes a consulting pharmacist who reviews your health record monthly to assess the appropriateness of medication use. When services are contracted, we may disclose your health information to our business associates so they can perform the job we’ve asked them to do. To protect your information, we require the business associate to appropriately safeguard your information in the form of a written contract.

Directory: Unless you notify us that you object, we may include certain limited information about you in the facility directory to assist our receptionist with telephone inquiries while you are a resident here. This information may include your name, location in the facility, your religious affiliation and your general condition, i.e. fair, stable, etc. This directory information, except for your religious affiliation, may also be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy such as a pastor, priest or rabbi, even if they do not ask for you by name. Unless you notify us that you object, we will post your first and last name outside of your room. Unless you object, we will include your first and last name and room number on our facility directory board. The directory provides information so your family, friends and clergy can visit you in the facility.

You are automatically included in the facility directory which allows Knute Nelson to relay your location and general condition if you are asked for by name. If you do not want to be included in this directory, you will inform the facility of your decision. If you opt out of this directory, it is understand that if family members, clergy, neighbors, or friends inquire about you while you are a resident, your presence here will not be disclosed, and that mail, gifts, or flowers addressed to you will be returned.

Sign Out Form: Your name will appear on a sign out log each time you leave the facility. This information is available to others while signing out and back in.

Visitor Book: Unless you notify us that you object, we will allow visitors to sign the visitor book which will include your name when family, friends or members of the community come to visit.

Member and/or Service Organizations: Unless you notify us that you object, we may release limited information about you such as your first/last name, location within our facility, and/or dates of stay to organizations based on a need to know basis as defined and agreed upon by our Privacy Committee. For example: Veterans of Military Service, Lions Club, Knights of Columbus (This list is not all inclusive). Your name, location within our facility and/or dates of stay may be given to a representative of the organization even if they do not ask for you by name.

Individuals Involved in Your Care: We may disclose Protected Health Information about you to a family member or friend who is involved in your medical care, or those who assist in payment for your care. This may include informing family and friends of your condition and if you are within the facility or out. We may also disclose Protected Health Information about you to an entity assisting in disaster relief efforts so that your family can be notified about your status.

As Required by Law: We may disclose Protected Health Information about you when required by federal, state or local laws.

To Avert a Serious Threat to Health and Safety: We may use and disclose Protected Health Information to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

Research: We may disclose information to researchers according to Minnesota State Law when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.

Organ and Tissue Donation Organizations: If you are an organ donor, we may disclose your Protected Health Information to organizations engaged in tissue and organ donation and transplantation.

Military and Veterans: If you are a member of the Armed Forces, we may disclose Protected Health Information about you as required by military command authorities. We may also disclose personal health information about foreign military personnel to the appropriate foreign military authority.

Marketing: We may verbally inform you about products, services or disease management programs available to you as treatment options.

Food and Drug Administration (FDA): We may disclose your name to the FDA regarding health information relative to adverse events with respect to food, supplement, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacements.

Workers Compensation: We may disclose Protected Health Information necessary to comply with laws relating to workers compensation or other similar programs established by law.

Public Health Risks as Required by Law: We may disclose your Protected Health Information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

Law Enforcement: We may disclose Protected Health Information for law enforcement purposes as required by law including: to comply with a court order, warrant, subpoena, summons, investigative demand or similar legal process; to identify or locate a suspect, fugitive, material witness, or missing person, when information is requested about the victim of a crime, if the individual agrees or under other limited circumstances, to report information about a suspicious death; to provide information about criminal conduct occurring at the facility, to report information in emergency circumstances about a crime or where necessary to identify or apprehend an individual in relation to a violent crime or an escape from lawful custody or in response to a valid subpoena.

Health Oversight Activities: We may disclose your Protected Health Information to a health oversight agency for activities authorized by law. These may include, for example; audits, investigation, inspections and licensure actions or other legal proceedings. These activities are necessary for the government oversight of the health care system, government payment or regulatory programs and compliance with civil rights laws.

Coroners, Medical Examiners and Funeral Directors: We may disclose Protected Health Information to a coroner or medical examiner. This may be necessary to identify a deceased person or determine the cause of death. We may also disclose Protected health Information about residents of the facility to funeral directors as necessary to carry out their duties.

National Security and Intelligence Activities: We may disclose Protected Health Information about you to authorized federal officials for intelligence, counter intelligence and other national security activities authorized by law.

Health Insurance: When applicable, a group health plan or health insurance issuer or HMO may disclose Protected Health Information per contract to the sponsor of the plan.

Although your health record is the physical property of the healthcare practitioner or facility that compiled it, the information belongs to you. You have the right to the following:

Right of Access to Protected Health Information: You have the right to inspect and/or receive a copy of medical information that may be used to make decisions about your care. This includes medical and financial records, but does not include psychotherapy notes that are filed separate from your medical record.

You may submit a request to the facility Privacy Officer either orally or in writing. If you request a copy for reviewing your current medical care, we will provide that without cost within 2 working days. For other requests, we may charge a fee for the costs of copying according to our facility policy and procedure. We will allow you to inspect your record within 24 hours (excluding hours occurring during a weekend or holiday) of your request. We may deny your request to inspect or receive copies in certain limited circumstances per MN State law. If you are denied access to your Protected Health Information, you may request that the denial be reviewed. Another licensed health care professional chosen by our facility will review your request and the denial. The facility will then comply with the outcome of the review.

Right to Request an Amendment: If you feel that the medical information maintained is incorrect or incomplete, you may request an amendment. You may make a request in writing to our facility’s Privacy Officer. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. We also may deny it if the information was not created by the facility, is not part of the Protected Health Information maintained by or for our facility, is not part of the information to which you have a right of access to; or is already accurate and complete as determined by the facility. If we deny your request for an amendment, we will give you a written denial including the reason for the denial and the right to submit a written statement disagreeing with the denial.

Right to Request Restrictions: You have the right to request restrictions on the use or disclosure of your Protected Health Information for treatment, payment, or health care operations. You also have the right to restrict the Protected Health Information we disclose about you to a family member, friend or others involved in your care or payment for your care. We will make reasonable efforts to honor your request unless the information is needed to provide you emergency treatment or you are being transferred to another health care institution or the disclosure is required by law. You must make your request in writing to our Privacy Officer. In your request, you must tell us; 1) what information you want to limit, 2) whether you want us to limit our use, disclosure or both, and 3) to whom you want limits to apply, example your family members.

Right to an Accounting of Disclosure: You have the right to request an “accounting of disclosure”. This is a list of the disclosures we made of your Protected Health Information. Not all disclosures are subject to this accounting requirement.

To request this list of an accounting of disclosures, you must submit a written request to our Privacy Office. Your request must state a time period which may not be longer than six years and may not include dates prior to April 14, 2003. The first list you request within a 12 month period will be free of charge. For additional requests within the 12 month period, we may charge you a fee for processing. We will notify you of the cost involved and you may choose to withdraw or modify your request before any costs are incurred.

If you believe your privacy rights have been violated you may file a written complaint with our Privacy Officer or with the Secretary of the Department of Health and Human Services. We will not retaliate against you if you file a complaint.

Other Uses of Protected Health Information: Other uses and disclosures of Protected Health Information not covered by this notice or the laws that apply will be made only with your written permission. If you provide us permission to use or disclose Protected Health Information about you, you may revoke that permission in writing at any time. If you revoke the 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 in good faith with your permission.

You have the right to request communication of your Protected Health Information by alternative means or at alternative locations.

We reserve the right to change our practices and to make the new provisions effective for all Protected Health Information we maintain. Should our information practices change, we will post the updated notice during your current stay or upon readmission and have copies available for distribution.