HIPAA Acknowledgement Form (pdf document). Please print and sign this form upon your first appointment visit.
NOTICE OF PRIVACY PRACTICES
This notice describes how behavioral health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
DecisionPoint Behavioral Health takes the privacy of your/your child's health information seriously. We are required by law to maintain that privacy and to provide you with this Notice of Privacy Practices. This notice is provided to tell you about our duties and practices with respect to your/your child's information.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION
The following categories describe different ways that we use and disclose your/your child's health information without your signed authorization. For each category, we explain what is meant and give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.
1. For Treatment - DecisionPoint Behavioral Health may use health information for treatment, health care, or other related services. We disclose health information to doctors, nurses, technicians, assistants, or other DecisionPoint Behavioral Health employees who are involved in your/your child's care. (Examples: For a referral for psychological testing or at your request for transfer of care to another clinician.)
2. For Payment - DecisionPoint Behavioral Health may use health information to bill and collect for the treatment and services we provide to you/your child. We may send health information to an insurance company or other third party for payment purposes. (Examples: Sending information for payment purposes in order for your insurance company to pay for the visit and services.)
3. For Health Care Operations - DecisionPoint Behavioral Health may use and disclose health information for quality health care, and to maintain and improve the quality of health care we provide. (Examples: Chart reviews or transcription services.)
4. As required by Law - DecisionPoint Behavioral Health will disclose health information when required to do so by federal, state, or local law. (Examples: In response to a court order or subpoena; reporting victims of abuse or criminal conduct.)
5. For Public Health Reasons - DecisionPoint Behavioral Health may disclose health information for public health activities. (Examples: Injury, or disability. Reporting problems with medications.)
6. Research - DecisionPoint Behavioral Health may use and disclose protected health information to researchers provided the research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your/your child's health information.
7. Worker's Compensation - DecisionPoint Behavioral Health may disclose your health information as authorized by and to the extent necessary to comply with worker's compensation laws or laws relating to similar programs.
8. Other ways we may use and disclose your Protected Health Information:
- Appointment reminders
- Treatment alternatives
- Health-related benefits
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 authorization. If you provide us authorization to use/disclose your/your child's health information, you may revoke that authorization, in writing, at any time. You understand that we are unable to take back any disclosures we have made under the authorization, and that we are required to retain our records of the care that we provided to you/your child.
YOUR HEALTH INFORMATION RIGHTS
You have the following rights regarding health information about you:
1. Right to Request Restrictions - You have the right to request a restriction or limitation on the health treatment, payment, or health care operations. You also have the right to request a limit on the health information we disclose about you/your child to someone who is involved in your/your child's treatment or for the payment for that care. In most cases, 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 you emergency treatment. To request restrictions, you must make your request in writing to our Privacy Officer, DecisionPoint Behavioral Health, 180 Lachenview Lane NW, Rochester, MN 55901. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you wants the limits to apply.
2. Right to Inspect and Copy - You have the right to inspect and copy health information that may be used to make decisions about you/your child's care. To inspect and copy health information that may be used to make decisions about you/your child, you can submit your request in writing to our Release of Information Clerk, DecisionPoint Behavioral Health, 180 Lachenview Lane NW, Rochester, MN 55901. If you request a copy of information, we may charge a fee for the costs of copying, mailing, or other supplies associated with your request. We will have 30 days to respond to your request for information that we maintain on site. If the information is stored off-site, we are allowed up to 60 days to respond but must inform you of this delay.
3. Right to Amend - You have the right to ask us to amend your/your child's health and/or billing information for as long as the information is kept by, DecisionPoint Behavioral Health, 180 Lachenview Lane NW, Rochester, MN 55901. To request an amendment, your request must be made in writing and submitted to; Privacy Officer, DecisionPoint Behavioral Health, 180 Lachenview Lane NW, Rochester, MN 55904. In addition, you must provide a reason that supports your request. 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 may deny your request if you ask us to amend information that:
- Was not created by us, unless the person or entity that created the information is no longer available to make the amendment.
- Is not part of the health information kept by DecisionPoint Behavioral Health.
- Is not part of the information, which you would be, permitted to inspect or copy.
- Is accurate and complete.
4. Right to an Accounting of Disclosures - You have the right to request a list of certain disclosures that we have made of your/your child's health information. To request this list of disclosures, you must submit your request in writing to; Privacy Officer, DecisionPoint Behavioral Health, 150 South Broadway, Suite A, Rochester, MN 55904. Your request must state a time period that may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in which form you want the list (for example; on paper, electronically). The first list you request within a 12-month period will be free. For additional lists during such 12-month period, DecisionPoint Behavioral Health may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
5. Request Confidential Communication - You have the right to request how we communicate with you to preserve your privacy. Your request must be in writing and must specify how or where we are to contact you. We will accommodate all reasonable requests.
6. Complaints - If you believe your/child's privacy rights have been violated, you may file a complaint with, DecisionPoint Behavioral Health or with the Secretary of Health and Human Services. To file a complaint with DecisionPoint Behavioral Health provide as much detail as you can about the suspected violation and send it to; Privacy Officer, DecisionPoint Behavioral Health, 150 South Broadway, Suite A, Rochester, MN 55904. You should know that there would be no retaliation for your filing a complaint.
View the Receipt of Acknowledgement.
If you have any questions about this Notice, please contact:
DecisionPoint Behavioral Health, 206 South Broadway, Suite 411A, Rochester, MN 55904. Phone: 507.261.7080