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CANNON FALLS SCHOOLS
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. THE PRIVACY OF
YOUR MEDICAL
_______________INFORMATION
IS IMPORTANT TO US.______________
Our Legal Duty
We are required by applicable
federal and state laws to maintain the privacy of your medical information. We
are also required to give you this notice about our privacy practices,
our legal duties, and your rights concerning your medical information. We must
follow the privacy practices that are described in this notice while it is in
effect. This notice takes effect {04/14/2004.}, and will remain in effect
until we replace it.
We reserve
the right to change our privacy practices and die terms, of this notice at any
time, provided that applicable law permits such changes. We reserve the right
to make the changes in our
Privacy practices and the
new terms of our notice effective
for all medical information
that we maintain, including medical information we created or received before
we made the changes. Before we make a significant change in our privacy
practices, we will change this notice and send the new notice to our health
plan subscribers at the time of the change.
You may request a copy of our notice at any time. For more information about
our privacy practices, or for additional copies of this notice, please contact
us using the information listed at the end of this notice.
{Cannon Falls Public Schools Organized
Health Care Arrangement
}
{This notice applies to the privacy practices of
share your medical information and the medical
the group health plans and health insurers or
information of others they serve with each other
HMOs listed below. These organizations
as needed for the payment activities and health
participant in an organized health care care
operations relating to our organized health
arrangement. As such, these organizations may care
arrangement.}
Our Uses and Disclosures of Your Medical
Information
We use and
disclose medical information about you as follows:
Treatment: We may disclose your medical information to a doctor or a
hospital, which asks us for it to assist in your treatment.
Payment: We may use
and disclose your medical information to pay claims from doctors, hospitals
and other providers for services delivered to you that are covered by your
health plan, to determine your eligibility for benefits, to coordinate
benefits, to examine medical necessity, to obtain premiums, to issue
explanations of benefits to the person who subscribes to the health plan in
which you participate, and the like.
Health Care Operations: We may
use and disclose your medical information to rate our risk and determine our
premiums for your health plan, to conduct quality assessment and improvement
activities, to credential providers, to engage in care coordination or case
management, to manage our business, and the like.
You and Your Authorization: We must disclose your medical information to
you, as described below in the Individual Rights section of this notice. You
may give us written authorization to use your medical information or to
disclose it to anyone for any purpose. If you give us an authorization, you
may revoke it in writing at any time. Your revocation will not affect any use
or disclosures permitted by your authorization while it was in effect. Without
your written authorization, we may not use or disclose your medical
information for any reason except those described in this notice.
Your Family and Friends: We may disclose to a family member, a friend, or
other persons you indicate are involved in your care or payment for your care,
your medical information that is directly relevant to their involvement. We
may use or disclose your name, location and general condition or death to
notify, or help with notification, of a family member, your personal
representative, or other persons involved in your care about your situation.
If you are present, we will give you the opportunity to object before we
disclose your medical information to these persons. If you are incapacitated
or in an emergency; we may disclose your medical information to these persons
if we determine that the disclosure is in your best interest.
{Your Employer or Organization
Sponsoring Your Health: We may disclose your medical information and the
medical information of others enrolled in your group health plan to the
employer or other organization that sponsors your group health plan to permit
it to perform plan administration functions. Please see your group health plan
document for a full explanation of the limited uses and disclosures that the
plan sponsor may make of your medical information in providing
plan administration. We may also disclose summary information about the
participants in your group health plan to the plan sponsor to use to obtain
premium bids for the health insurance coverage offered through your group
health plan or to decide whether to modify, amend or terminate your group
health plan. The summary information we may disclose summarizes claims
history, claims expenses, or types of claims experienced by the participants
in your group health plan. The summary information will be stripped of
demographic information about the participants in the group health plan, but
the plan sponsor may still be able to identify you or other participants in
your group health plan from the summary information.}
{Underwriting; we may receive
your medical information for underwriting, premium rating or other activities
relating to the creation, renewal or replacement of a contract of health
insurance or health benefits. We will not use or further disclose this
medical information for any other purpose, except as required by law, unless
the contract of health insurance or health benefits is placed with us. In
that case, our use and disclosure of your medical information will only
be as described in this notice.}
Disaster
Relief; We may use or disclose your name, location and general condition or
death to a public or private organization authorized by law or by its charter
to assist in disaster relief efforts.
Death: Organ Donation:
We may disclose the medical information of a deceased person to a coroner,
medical examiner, funeral director, or organ procurement organization for
certain purposes.
Research; We may use or
disclose your medical information for research purposes, in accordance with
certain safeguards.
Public Health and Safety: We may
disclose your medical information to the extent necessary to avert a serious
and imminent threat to your health or safety or the health or safety of
others. We may disclose your medical information to a government agency
authorized to oversee the health care system or government programs or its
contractors, and to public health authorities for public health purposes. We
may disclose your medical information to appropriate authorities if we
reasonably believe that you are a possible victim of abuse, neglect, domestic
violence or other crimes.
Required by Law: We may use or disclose your medical information when we are
required to do so by law. For example, we must disclose your medical
information to the U.S. Department of Health and Human Services upon request
for purposes of determining whether we are in compliance with federal privacy
laws. We may disclose your medical information when authorized by workers'
compensation or similar laws.
Process and Proceedings: We may disclose your medical information in
response to a court or administrative order, subpoena, discovery request, or
other lawful process, in accordance with specified procedural safeguards.
Law Enforcement: Under circumstances, such as a court order, warrant, or grand
jury subpoena, we may disclose your medical information to law enforcement
officials. We may disclose limited medical information to a law enforcement
official concerning a suspect, fugitive, material witness, crime victim or
missing person. We may disclose the medical information of an inmate or
other person in lawful custody to a law enforcement official or correctional
institution. We may disclose medical information where necessary to
assist law enforcement officials to capture an individual who has admitted
to participation in a crime or has escaped from lawful custody.
Military and National Security: We may disclose to military authorities
the medical information of armed forces personnel under certain
circumstances. We may disclose to authorized federal officials medical
information required for lawful intelligence, counterintelligence, and other
national security activities.
Access: You have the right to look at or get
copies of your medical information, with limited exceptions. You may request
that we provide copies in a formal other than photocopies. We will use the
format you request unless we cannot practicably do so. {You must make a
request in writing to obtain access to your medical information. You may
obtain a form to request access by using the contact information listed at the
end of this notice. You may also request access by sending us a letter to the
address at the end of this notice. If you request copies, we will charge you
$0.25 for each page, $25.00 per hour for staff time to locate and copy your
medical information, and postage if you want the copies mailed to you. If you
request an alternative format, we will charge a cost-based fee for providing
your medical information in that format. If you prefer, we will prepare a
summary or an explanation of your medical information for a fee. Contact us
using the information listed at the end of this notice for a full explanation
of our fee structure.}
Disclosure Accounting: You have the right to
receive a list of instances in which we or our business associates disclosed
your medical information for purposes other than for treatment, payment,
health care operations, and limited other activities. You are entitled to such
an accounting for the 6 years prior to your request, though not earlier than
April 14, 2004. We will provide you with the date on which we made a
disclosure, the name of the person or entity to which we disclosed your
medical information, a description of the medical information we disclosed,
the reason for the disclosure, and certain other information. If you request
this list more than once in a 12-month period, we may charge you a reasonable,
cost-based fee for responding to these additional requests. Contact us using
the information listed at the end of this notice for a full explanation of our
fee structure.
Restriction Requests: You have the right to request that we place additional
restrictions on our use or disclosure of your medical information for
treatment, payment, health care operations or to persons you identify. We are
not required to agree to these additional restrictions, but if we do, we will
abide by our agreement (except in an emergency). {Any agreement we may make to
a request for additional restrictions must be in writing signed by a person
authorized to make such an agreement on our behalf. We will not be
bound unless our agreement is so memorialized in writing.}
Confidential Communication: You have the right to request that we communicate
with you in confidence about your medical information by alternative means or
to an alternative location. {You
must make your request in writing, and you must state that the information
could endanger you if it is not communicated in confidence as you request.} We
must accommodate your request if it is reasonable, specifies the alternative
means or location, and continues to permit us to collect premiums and pay
claims under your health plan, including issuance of explanations of benefits
to the subscriber of the health plan in which you participate. An explanation
of benefits may contain sufficient information to reveal that you obtained
healthcare for which we paid, even though you requested that we communicate
with you about that health care in confidence.
Amendment:
You have the right to request that we amend your medical information. {Your
request must be in writing, and it must explain why the information should be
amended.} We may deny your request if we did not create the information you
want amended or for certain other reasons. If we deny your request, we will
provide you a written explanation. You may respond with a statement of
disagreement to be appended to the information you wanted amended. If we
accept your request to amend the information, we will make reasonable efforts
to inform others, including people you name, of the amendment, and to include
the changes in any future disclosures of that information.
Electronic Notice: If you receive this notice on our web site or by electronic
mail (e-mail), you are entitled to receive this notice in written form. Please
contact us using the information listed at the end of this notice to obtain
this notice in written form.
If you
want more information about our privacy practices or have questions or
concerns, please contact us using the information listed at the end of this
notice.
If you are
concerned that we may have violated your privacy rights, or you disagree with
a decision we made about access to your medical information or in response to
a request you made to amend or restrict the use or disclosure of your medical
information or to have us communicate with you in confidence by alternative
means or at an alternative
Contact Office:
CANNON FALLS DISTRICT OFFICE
Telephone: 507-263-3331 #7
E-mail: hanson.lori@cannonfallsschools.com
Address: 820 E. Minnesota Street
Cannon Falls, MN 55009
Fax:
507-263-2555
location, you may complain to us
using the contact information listed at the end of this notice. You also may
submit a written complaint to the U.S. Department of Health and Human
Services. We will provide you with the address to file your complaint with the
U.S. Department of Health and Human Services upon request.
We support your right to protect the privacy of your medical information. We
will not retaliate in any way if you choose to file a complaint with us or
with the U.S. Department of Health and Human Services.
Dated:
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