Notice of Privacy Practices

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.

What is this Notice for?
The Notice of Privacy Practices tells you about your rights under a federal law called the Health Insurance Portability and Accountability Act—or HIPAA for short. This law protects your medical information and sets rules about who can see it and get access to it.

What is your information?
In this notice, when we use the term “your information”, we mean information that identifies you and relates to your health or condition, your health care services, or payment for those services. It includes health information (like diagnosis and treatment plans) and demographic information (like your name, address, phone number, and date of birth). It also includes any information, whether oral, electronic, or paper, which is created or received by Essentia Health and is related to your health care or payment for the provision of medical services. The information documenting the care and services you receive from Essentia Health is contained in a medical record, which is the physical property of Essentia Health. We need this record to provide you with quality care, the bill for your care, and meet legal requirements.

Why are you getting this Notice?

Your privacy is important to us. The law requires that you be given a copy of this notice so that you can:

know your rights;
use your rights;
ask questions about your rights;
file a complaint if you think your rights may have been violated; and
know that we will notify you if we become aware of a breach of your information.

Who will follow this Notice?

This Notice applies to all Essentia Health entities and healthcare practice sites located in Minnesota, Wisconsin, and North Dakota (collectively referred to as “Essentia Health”). You can find a list of current Essentia Health locations at www.essentiahealth.org.

This Notice applies to all of the records of your care that we maintain, whether made by our staff (such as physicians, nurses, therapists, support staff, volunteers, and authorized trainees), or by other health care providers not employed by Essentia Health.

This Notice describes Essentia Health’s practices and that of all:

departments, hospitals, clinics, and other locations;
residents, medical students, and other trainees affiliated with Essentia Health;
volunteers who may assist you; and
employees, staff, and contractors.

Federal and State Laws

Health information may be protected by both federal and state laws and regulations. Essentia Health is required to follow both sets of rules. Sometimes these rules are different. In those cases, Essentia Health follows the rules that give more protection of health information and grant our patients more rights. Where a state law is stronger, we will follow the state law.

Use and Disclosure of Your Health Information

To provide you with the most comprehensive and high-quality care, we will need to use and disclose your health information. When we use and disclose your health information, we will follow the law and take steps to protect your information. We may use and disclose your health information in these ways:

For Treatment, Payment, and Health Care Operations

To Treat You (Treatment): We use and share your information to treat you. We share it with other professionals and non-Essentia organizations that treat you or manage your care. This makes your care safe and coordinated.

Examples:

As your primary care physician, we tell a specialty doctor who is treating you what medicines you’re taking. This prevents dangerous drug interactions.
After orthopedic surgery, your doctor may refer you for rehabilitation. Information will be shared between caregivers to ensure continuity of care.

Please note that we are not required to obtain your permission to share your information in a medical emergency if you can’t give us permission due to your condition.

To Bill For Your Services (Payment): We can use and share your information to bill and get paid by health plans and others for care that you receive.

Examples:

We may give your health plan information about the services you receive so it will pay us, or reimburse you, for those services.
We may contact your health plan to see if a service is covered before we provide that care.

To Run Our Organization (Health Care Operations): We may use and share your health information to help run our organization and make sure that all of our patients are receiving quality care.

Examples:

We may use your information for quality improvement activities throughout Essentia Health, evaluating our physicians and staff, conducting training activities, obtaining legal and accounting services, conducting audits, business planning, and other management activities.
We may share your information with business associates - those we partner with to provide services on our behalf but who aren’t our employees or affiliates. These partners are required by law to safeguard your information the same way we do.

Additional applicable state law requirements: Minnesota law generally requires patient consent for disclosures of health information by Essentia Health Minnesota entities for treatment, payment, and health care operation purposes, unless the disclosure is to an Essentia Health-related entity or consent is not possible due to a medical emergency. These disclosures are described on the General Consent & Authorization form that you are asked to sign.

Additional applicable state law requirements: For Minnesota residents – Essentia Health will give your immunization information to the Minnesota Department of Health via the Minnesota Immunization Information Connection (MIIC). MIIC is a confidential system that stores electronic immunization records. MIIC makes it easy to keep track of vaccinations and helps ensure Minnesotans get the right vaccines at the right time. If you do not want your immunization information to go to the MIIC, you can choose to opt-out on the General Consent & Authorization form that you sign. Or you can tell a Registration Representative that you wish to opt-out.

Shared Electronic Health Record/Health Information: Essentia Health’s electronic health record allows care providers, other approved users within Essentia Health, and some non-Essentia Health facilities (under a contractual relationship) to store, update and/or access your health information as long as you have received care at those facilities. Care providers and approved users may access your health record at the time you are seeking care, even if they work at other care facilities, clinics, or hospitals. A shared health record ensures smooth care coordination and improves the quality of your care. For example, if you are brought to a hospital in an emergency and cannot tell the provider what is wrong, the facility may access your information that is stored in your Essentia Health electronic health record if allowed by contract or law.

Health Information Exchange: We may make your protected health information available electronically through an electronic health information exchange to other health care providers that request your information for their treatment purposes. In all cases, the requesting provider must have or have had a treating relationship with you. Participation in an electronic health information exchange also lets us see other providers’ information about you so we can treat you.

Appointment Reminders and Treatment Alternatives: Essentia Health may access your health information to set up or remind you about future appointments. We may use and share your health information to tell you about treatment options and health-related benefits or services that you may be interested in. Essentia Health, its affiliates, and agents may use an automated telephone dialing system, and texting, to contact the home phone and cellular telephone number(s) you gave us for appointment and payment purposes and other important notifications.

Marketing: In general, Essentia Health must get your written authorization before using your health information for marketing purposes.

Without your written authorization, we can:

give you marketing materials in a face-to-face encounter;
tell you about products or services relating to your treatment;
communicate with you to coordinate or manage your care; and
give you information about different treatments, providers, or care settings.

Patient directory: While you are a patient at Essentia Health, friends, family, and others may call to ask about you. If someone calls and asks for you by name, we will tell them your location so that they may call or visit you. If they ask, we will also tell them in general terms how you are doing (doing well, serious condition, etc.). If you ask us to list your faith community (or religious affiliation) in the directory, we will also share this information with a leader from your faith community (priest, minister, rabbi, or other spiritual advisor) if they ask.

If you do not want us to tell anyone that you are here, please tell us when you are being registered or tell your care team during your stay.

Fundraising: Essentia Health may contact you about supporting our fundraising efforts, programs, and events to support our mission. We may use certain information (name, date of birth, address, email address, telephone number, dates of service, age, gender, department of service, treating physician, outcome information, and health insurance status) to contact you in the future to raise money for Essentia Health.

We may also disclose this information to our institutionally-related foundations for the same purposes. We do not sell or rent patient names or contact information to organizations outside the Essentia Health family without your authorization.

If, upon receiving a fundraising communication, you wish to opt-out from receiving further fundraising communications, please refer to the opt-out instructions provided in the letter or form sent to you.

Research: Conducting research is an important part of Essentia Health’s mission. Research projects conducted by Essentia Health must be approved through a special review process to make sure patient safety, welfare, and confidentiality are protected. We may use and disclose information about our patients for research purposes only as permitted by applicable law. In some instances, federal law allows us to use your information for research without your authorization, provided we get approval from a special review board. Your treatment and welfare will not be affected, and your information will be protected.

Additional applicable state law requirements: Minnesota law generally requires patient consent for disclosure of protected health information by Essentia Health Minnesota entities to outside researchers for research purposes. Essentia Health Minnesota entities will obtain consent from their patients or will make a good faith effort to obtain consent before releasing health records to an external researcher. Wisconsin law generally requires patient consent before we may disclose health information for research purposes to a researcher who is not affiliated with Essentia Health. In some situations, we may disclose health information for research purposes to a researcher who agrees to protect the privacy of your information.

Family Members and/or Support Person(s) Involved in Your Care: Essentia Health may disclose relevant protected health information to a family member or support person who is involved in your care. We find that many patients want us to discuss their care with family members and support persons to help them understand their care, to help in handling bills, or to help schedule appointments. In a disaster situation, we also may disclose relevant protected health information to disaster relief organizations to help locate your family members or others to inform them of your location, condition, or death. Essentia Health may also disclose your protected health information to a personal representative who has the authority to make health care decisions on your behalf. If a family member or support person is present while care is being provided, Essentia Health will assume your companion(s) may hear the discussion, unless you state otherwise.

To Prevent a Serious Threat to Health or Safety: We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of others. However, this would only be to someone able to help prevent the threat. In addition, Minnesota law permits disclosures only if specifically required by law or with your written consent. There are a few circumstances in which Essentia Health professionals have a “duty to warn” potential victims or law enforcement officials of specific threats.

Organ and Tissue Donation: If our health care professionals find that you may be a candidate to donate organs or tissue, consistent with applicable law, we may disclose your health information to health care providers, organizations, or other entities involved in the procurement, banking, or transplantation of organs/tissue.

Military Authorities/National Security: When required by law, we may release protected health information to authorized federal officials for military, intelligence, counterintelligence, or other national security activities. Essentia Health may also disclose protected health information to authorized federal officials so they may provide protection to the President or other authorized individuals.

Workers’ Compensation: If you are seeking workers' compensation for a work-related illness or injury, we may release health information related to your claim, as permitted or authorized by the state Workers' Compensation program.

Public Health Purposes: We may disclose health information about you for legally authorized or required public health activities. Examples include, but are not limited to:

preventing or controlling disease;
injury or disability;
reporting births and deaths;
reporting reactions to medications or problems with products;
notifying people of recalls of products they may be using; and
notifying a person who may have been exposed to a communicable disease or may be at risk for contracting or spreading a disease or condition.

Additional applicable state law requirements: Wisconsin law allows a physician or optometrist to report a patient’s name and other information relevant to the patient’s condition to the Wisconsin Department of Transportation. The physician may do so without the patient’s permission if he/she believes that the patient’s condition affects their ability to safely operate a motor vehicle. Wisconsin law generally requires patient consent to disclose information from mental health treatment records and HIV test results, unless the disclosure is otherwise authorized or required by law.

Minnesota law allows a physician to report a patient’s name and information about their physical or mental condition to the Minnesota Department of Public Safety. The physician may do so without the patient’s permission if he/she believes that the patient’s condition affects their ability to safely operate a motor vehicle.

Health Oversight Activities: We may disclose health information for health oversight activities as authorized by law. Examples of oversight activities include audits, investigations, inspections, and licensing. These activities are needed for the government to oversee the health care system.

Judicial and Administrative Proceedings: We may disclose your health information in the course of any judicial or administrative proceeding as required or permitted by law, including in response to a court/administrative order, subpoena, or similar process.

Law Enforcement: We may share health information with governmental authorities, including law enforcement, social services, or protective services agencies:

in response to a court order, grand jury subpoena, warrant, summons, or similar process;
to identify someone who has died;
to locate a missing person;
about a death we believe may be the result of criminal conduct;
about a victim of abuse, neglect, or domestic violence;
about criminal conduct at the health care facility, in emergency situations to report a crime, the location of the crime or victims, or the identity, description, or location of the person who committed the crime; and
in other situations as required by law.

If you are an inmate of a correctional institution, we may disclose your health information to the institution or agents if it is needed for your health and the health and safety of other individuals, in accordance with state and federal requirements.

Additional applicable state law requirements: Minnesota and Wisconsin law generally require patient consent for disclosures of protected health information by Essentia Health entities for law enforcement purposes, unless the disclosure is in response to a valid court order or warrant.

Patient Safety Room Surveillance: In some patient rooms video surveillance may be used for the purposes of patient safety and treatment. These images are not recorded. We will post signs where video surveillance is in use.

Required by Law: We will use or disclose your protected health information when required by federal, state, or local laws. For example, Essentia Health is required to report:

certain gunshot wounds and other injuries that may have resulted from an unlawful act
abuse or neglect of a child or vulnerable adult.

Work with a coroner, medical examiner, or funeral director: We can share health information with a coroner, medical examiner, or funeral director when a person dies.

Additional applicable state law requirements: Minnesota law generally requires the consent of a patient’s authorized family or legal representative for disclosures of health information to funeral directors. Wisconsin law generally requires the consent of a patient’s authorized family or legal representative to release health information to funeral directors. However, HIV test results and certain other health information may be disclosed to a funeral director when necessary to permit the funeral director to carry out his/her duties.

Information with Additional Protections: Certain types of health information may have additional protection under federal or state law. For example, HIV/AIDS and genetic testing results have additional protections under certain state laws. In many circumstances, Essentia Health would need to get your written authorization before disclosing that information to others.

Confidentiality of Substance Use Disorder Patient Records: Certain Essentia Health facilities, units, and staff specialize in providing substance use disorder treatment (Programs). The confidentiality of substance use disorder patient records maintained by these Programs may be protected by special federal law and regulations, in addition to HIPAA. Generally, such a Program may not say to a person outside the Program that a patient attends the Program, or disclose any information identifying a patient as having or having had a substance use disorder unless:

The patient consents in writing;
The disclosure is allowed by a court order; or
The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation.

A violation of these laws is a crime and may be reported to the appropriate authorities.

Uses & Disclosures With Your Authorization: We may only use or disclose your health information with your written permission except as described in this Notice or specifically required or permitted by law.

If you give written permission, you have the right to withdraw your permission for future uses and disclosures by notifying Essentia Health in writing.

Individual Rights
This section describes your rights as an Essentia Health patient related to your health information:

Right to View and Copy: You have the right to request, in writing, to view and get a copy of the health information that we use to make decisions about your care. You have the right to ask the copy be provided in an electronic form or format (e.g., PDF saved onto a thumb drive). If the requested form or formats are not easy to produce, we will work with you to provide them in a reasonable electronic form or format. Essentia Health generally may charge a reasonable, cost-based fee to cover the expense of providing the copies. If we deny your request to view or obtain a copy of your health information, you can request that the denial be reviewed.

To make such a request, please contact the Essentia Health Release of Information Department.

Additional applicable state law requirements: Minnesota law requires written and legally compliant patient consent for disclosures of health information to the patient themselves. Therefore, the proper Essentia Health form must be completed and received prior to such access being granted.

Right to Request Alternate Methods of Communication: You have the right to ask, in writing, that confidential communications about you be made in an alternative manner (such as by phone or secure messaging) or at a certain location. You do not need to state a reason. We will strive to meet all reasonable requests. Your request must state exactly how or where you wish to be contacted in the future.

To make such a request, please contact an Essentia Health Registration department or contact the Essentia Health Privacy Officer at [email protected] or (218) 786-1172.

Right to Request Amendment: If you feel that the health information we have about you is incorrect or incomplete, you can ask us to change it. If we agree to make the amendment to your health information, we will make a reasonable effort to give the revised information to those with whom we previously disclosed the original information.

We may say “no” to your request, but we’ll tell you why in writing as quickly as possible. In that case, you can ask us to keep a copy of your disagreement (a written statement you provide to us) with your records.

To ask for a change, please contact the Essentia Health Information Services department and they will provide the necessary form to be completed.

Right to a List of Certain Disclosures: You have the right to ask, in writing, for a list of disclosures we have made of your health information. This list will not include uses and disclosures for treatment, payment, and healthcare operations, as previously described, as well as those for which you have authorized disclosure. Your request must state a time period, which may not be longer than six years. The first list requested within a 12-month period shall be provided at no charge. For more lists requested during the same 12-month period, Essentia Health may charge for the costs of providing the list.

To make such a request, please contact the Essentia Health Release of Information department.

Right to Request Restrictions: You can ask Essentia Health to restrict the use or disclosure of protected health information about you for treatment, payment, or health care operations. We will carefully consider all requests. However, because of the integrated nature of Essentia Health’s medical record, we are not generally able to honor most requests, nor is Essentia Health legally required to do so. If you or someone on your behalf pays for a health care item or service out-of-pocket and in full, you can request that Essentia Health not disclose information about the item or service to your health plan for payment or health care operations purposes, and we will agree to your request unless required by law to make the disclosures.

To ask for a restriction, please contact the Essentia Health Privacy Officer at [email protected] or (218) 786-1172 and they will provide the necessary form to be completed.

Key Information about this Notice
This is a revised notice for Essentia Health. The effective date of this revised notice is November 16, 2021.
Essentia Health may change its practices of how we use or disclose protected health information, or how we will implement patient rights concerning their information. We reserve the right to change the terms of this notice.
We will make any revised Notice available in hard copy and display it in our locations and on our website.

If you have any questions or would like to discuss this Notice in more detail, please contact the Essentia Health Privacy Officer at [email protected] or (218) 786-1172.

Complaints
If you are concerned that your privacy rights may have been violated, please contact the Essentia Health Privacy Officer at [email protected] or (218) 786-1172.

You may also send a written complaint to the United States Department of Health & Human Services- Office for Civil Rights. Our Privacy Officer can provide you with information on how to file such a complaint.

Under no circumstances will we ever ask you to waive your rights under this Notice or retaliate against you in any manner for filing a complaint.

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Notice of Privacy Practices

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