Notice of Privacy Practices



By filling out the following NOTICE OF PRIVACY PRACTICES form, I am acknowledging that I have been informed of the risks, including but not limited to my confidentiality in services, of transmitting my protected health information by unsecured means. I understand that I am not required to sign this agreement in order to receive requested services. I also understand that I may terminate this consent at any time.

If you have questions about this notice or want more information, please contact: Terence Eich, Privacy Officer at 507-287-2010. The effective date of this notice is July 1 2020.

To appropriately treat you and receive payment for the services we provide, we may need to collect information from you including your full name and address, insurance company, medical history, and current medical conditions. We may use and share the information we collect about you in the ways described below.

We may change the terms of this Notice and the revised Notice will apply to all health information in our possession. If we change this Notice, a copy of the new Notice will be posted and a copy may be requested from our Privacy Officer.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. You have the choice to tell us to:

  • Share information with your family, close friends, or others involved in your care to the extent the information is relevant to their involvement.
  • Share information with public or private agencies for disaster relief purposes.

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In other cases, we will not share your information unless you give us written permission. These cases include:

  • Psychotherapy Notes. We will not use or share your psychotherapy notes without a written authorization except as specifically permitted by law.
  • Marketing. We will not use or share your information for marketing purposes, other than face-to-face communications with you or promotional gifts of nominal value, without your written authorization.
  • Sale of Information. We will not sell your PHI without your written authorization, including notification of the payment we will receive.

Your Rights

  • You have the right to request that we limit how information about you is used and shared. If you pay for a service in full, you can ask us not to share that information with your insurer for the purpose of payment or our operations and we are required to agree to this request.
  • You have the right to request communications with you be made at an alternative address or phone number.
  • You have the right to inspect and copy your medical record & other health information.
  • If you believe the information we have about you is incorrect or incomplete you may request that we correct your medical record.
  • You have the right to receive a list of those with whom we have shared your information. This list will not include certain situations such as when we share your information for treatment, payment, or healthcare operations.
  • You have the right to request a paper copy of this Notice.
  • When you have given us permission in writing to use or share your information, you have the right to change your mind at any time. Let us know in writing if you change your mind.
  • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
  • We will make sure the person has this authority and can act for you before we take any action.
  • You have the right to file a complaint. If you believe your privacy rights have been violated you may contact: Terence Eich, Privacy Officer at 507-284-2010 or 4600 18th Ave. NW, Rochester, MN 55901 or the Office of Civil Rights. You will not be penalized for filing a complaint.
  • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to: 200 Independence Ave S.W. Washington, D.C. 20201, or Calling 1-877-696-6775, or visiting
  • We will not retaliate against you for filing a complaint.

Other Times We May Share Your Information

We may use or share your information for the following purposes without additional written permission from you to:

  • Treat You. We may use and share your information to provide you with healthcare services. Your information may be shared to hospitals and other healthcare professionals providing care to you. For example, we may coordinate your care with your primary care physician or an in-home care professional who provides services to you.
  • Bill for Our Services. We may use and share your information to receive payment for the services and treatment provided to you. We use your information to create a bill and share your information when we send the bill to your insurance company, you, or a third party. The individual or entity paying the bill may request more information to determine whether the bill is covered by your insurance. We may tell your health plan about a treatment you are going to receive to get approval for payment or to determine whether your health plan will cover the treatment.
  • Run Our Organization. We may use and share your information to run our organization, improve your care, and contact you when necessary. For example, we may use your information to monitor the quality of the services that we provide to you or to remind you of upcoming appointments.
  • Provide Treatment Alternatives. We may provide you with information about treatment alternatives and other health related benefits and services.

There are other situations in which we may be permitted or required to share your information. We must meet specific conditions in the law before we can share your information for these purposes. Before we share your information for these purposes we will make sure that the requirements of any state or federal law are met. Your information may be used to:

  • Comply with the Law. We share information as required by law. For example, we are required to report suspected abuse, neglect, or domestic violence. We are also required to provide information to the Secretary of the Department of Health and Human Services to demonstrate our compliance with HIPAA.
  • Help with Public Health. We may share information to health agencies as necessary to prevent or control the spread of disease, help with product recalls, and maintain the safety of our community.
  • Prevent a Serious Threat to Health or Safety. We may share information about you to law enforcement or an identified victim to prevent a serious threat to your health or safety or the health or safety of another individual or the public.
  • Fundraising. We may use your information to contact you regarding our fundraising efforts. You have a right to opt out of these communications.
  • Satisfy Other Specific Requirements or Requests. There are other situations in which we may be required or permitted to share your information. These situations include disclosures to researchers for approved research; to government agencies and boards as necessary for investigations, audits, licensing and compliance; to respond to a court order or subpoena in a judicial or administrative proceeding; in response to law enforcement activity such as a warrant or summons; for organ procurement or coroner functions; for workers’ compensation claims; for specialized government functions such as military or national security; or to a correctional institution if you are inmate. More information regarding these situations is available to you at consumers/index.html.

If Minnesota law provides additional protections to your information, we will comply with the additional requirements under Minnesota law prior to using or disclosing your information. For example, if you receive services through the county, we will comply with the additional requirements of the Minnesota Government Data Practices Act, as described in the county’s notice of privacy practices prior to using or disclosing your information.

Our Responsibilities

  • We are required by law to maintain the privacy of your protected health information.
  • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
  • We are required to notify you if there is a breach that affects the privacy or security of your information.
  • We must follow the duties and privacy practices described in this notice and give you a copy of it.
Name of Client *:
Date *:
E-Signature of Client or Legal Guardian *:

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