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.

Our Duty to Safeguard Your Protected Health Information

Individually identifiable information about your past, present, or future health or condition, the provision of health care to you, or payment for health care is considered “Protected Health Information” (PHI). We are required to extend certain protections to your PHI, and to give you this Notice about our privacy practices that explains how, when and why we may use or disclose your PHI. Except in specified circumstances, we must use or disclose only the minimum necessary PHI to accomplish the intended purpose of the use or disclosure.

We are required to follow privacy policies described in this Notice though we reserve the right to change our privacy practices and the terms of this Notice at any time. You may request a copy of the new Notice from our main office or your therapist.

How We May Use and Disclose Your Protected Health Information

We use and disclose Personal Health Information for a variety of reasons. We have a limited right to use and/or disclose your PHI for purposes of treatment, payment and for our health care operations. For uses beyond that, we must have your written authorization.

Uses and Disclosures Relating to Treatment, Payment, or Health Care Operations

Generally, we may use or disclose your PHI as follows:

For treatment: We may disclose your PHI to doctors, and other health care personnel who are involved in providing your health care. For example, your PHI may be shared among clinical staff in consultation meetings. Your PHI may also be shared with outside entities performing ancillary services relating to your treatment, such as lab work.

To obtain payment: We may use/disclose your PHI in order to bill and collect payment for your health care services. For example, we may release portions of your PHI to the Medicaid program, state or county referral agencies, and/or a private insurer to get paid for services we delivered to you.

For health care operations: We may use/disclose your PHI in the course of operating our facility. For example, we may use your PHI in evaluating the quality of services provided, disclose your PHI to our accountant or attorney for audit purposes, or to our computer programmer for similar purposes.

Uses and Disclosures of PHI Requiring Authorization

For uses and disclosures beyond treatment, payment and operation purposes, we are required to have your written authorization, unless the use or disclosure falls within one of the exceptions described below. Authorizations can be revoked at any time to stop further uses/disclosures except to the extent that we have already undertaken an action in reliance upon your authorization.

Uses and Disclosures of PHI Not Requiring Consent or Authorization

The law provides that we may use/disclose your PHI from mental health records without consent or authorization in the following circumstances:

When required by law: We may disclose PHI when a law requires that we report information about suspected abuse, neglect or domestic violence, or relating to suspected criminal activity, or in response to a court order. We must also disclose PHI to authorities that monitor compliance with these privacy requirements.

For public health activities: We may disclose PHI when we are required to collect information about disease or injury, or to report vital statistics to the public health authority.

For health oversight activities: We may disclose PHI to a health oversight agency for activities authorized by law. Examples of oversight activities include audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Relating to decedents: We may disclose PHI related to a death to coroners, medical examiners or funeral directors, and to organ procurement organizations relating to organ, eye, or tissue donations or transplants.

For research purposes: By performing research, we learn new or better ways to diagnose and treat illnesses. Relate will not use or disclose your health information to external researchers unless you authorize the disclosure in writing.

To avert serious threat to health or safety: In order to avoid serious threat to health or safety, we may disclose PHI as necessary to law enforcement or other persons who can reasonably prevent or lessen the threat of harm.

For specific government functions: We may disclose PHI to authorized federal officials so they may provide protection to the President, or authorized persons or foreign heads of state or conduct special investigations.

Workers’ Compensation: If you are being treated for a work-related injury or condition, we may release PHI about you for workers’ compensation or similar programs. These programs provide benefits for work related injuries or illness.

Military and Veterans: If you are a member of the armed forces, we may release PHI about you as required by military command authorities. We may also release PHI about foreign military personnel to the appropriate foreign military authority.

Law Enforcement: We may release PHI if asked to do so by a law enforcement official:

In response to a court order; About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement; About a death we believe may be the result of criminal conduct; In other situations as required by law.

Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose PHI about you in response to a court or administrative order. We may also disclose PHI about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Uses and Disclosures Requiring You to Have an Opportunity to Object

In the following situation, we may disclose a limited amount of your PHI if we inform you about the disclosure in advance and you do not object, as long as the disclosure is not otherwise prohibited by law. To families, friends or others involved in your care: We may share with these people information directly related to their involvement in your care, or payment for your care. We may also share PHI with these people to notify them about your location, general condition, or death.

Your Rights Regarding Your Protected Health Information

You have the following rights relating to your protected health information:

To request restrictions on uses/disclosures: You have the right to ask that we limit how we use or disclose your PHI. We will consider your request, but are not legally bound to agree to the restriction. To the extent that we do agree to any restriction on our use/disclosure of your PHI, we will put the agreement in writing and abide by it except in emergency situations. We cannot agree to limit uses/disclosures that are required by law.

To choose how we contact you: You have the right to ask that we send your information to an alternative address or by an alternative means. We must agree to your request as long as it is reasonably easy for us to do so.

To inspect and request a copy of your PHI: Unless your access to your records is restricted for clear and documented treatment reasons, you have a right to see your PHI upon your written request. We will respond to your request within 30 days. If we deny your access, we will give your written reasons for the denial and explain any right to have the denial reviewed. If you want copies of your PHI, a charge for copying may be imposed, depending on your circumstances. You have a right to choose what portions of your information you want copied and to have prior information on the cost of copying.

To request amendment of your PHI: If you believe that PHI we have about you is incorrect or incomplete, you may request, in writing that we correct or add to the record. We will respond within 60 days of receiving your request. We may deny the request if we determine that the PHI is (1) correct and complete; (2) not created by us and/or not part of our records, or (3) not permitted to be disclosed. Any denial will state the reasons for denial and explain your rights to have the request and denial, along with any statement in response that you provide, appended or link to your PHI. If we approve the request for amendment, we will change the PHI and so inform you, and tell others that need to know about the change in the PHI.

To find out what disclosures have been made: You have a right to receive a list of when, to whom, for what purpose, and what content of your PHI has been released other than instances of disclosure: for treatment, payment, and operations; to you, your family; or pursuant to your written authorization. The list also will not include any disclosures made for national security purposes, to law enforcement officials or correctional facilities, or disclosures made before April 2003. We will respond to your written request for such a list within 60 days of receiving it. Your request can relate to disclosure going as far back as six years. There will be no charge for up to one such list each year. There may be a charge for more frequent requests.

You Have the Right to Receive This Notice

You have a right to receive a copy of this Notice upon request. 

How to Complain About Our Privacy Practices

If you believe your privacy rights have been violated, or you disagree with a decision we made about access to your Protected Health Information (PHI), you may file a complaint with the Contact Person(s) listed below. You may also file a written complaint with the Secretary of the U.S. Department of Health and Human Services at 200 Independence Avenue SW, Washington D.C., 20201 or call 1-800-696-6775. We will take no retaliatory action against you if you make such complaints.

Contact Person for Information or to Submit a Complaint

If you have questions about this Notice or any complaint about our privacy practices, please contact: Relate Counseling Center

5125 County Road 101

Minnetonka, MN 55345

Phone #: 952-932-7277 

Or:

Commissioner, State of Minnesota 

Department of Human Services 

444 Lafayette Road

St. Paul, MN 55155 

Phone #: 651-296-3971

Click Here for downloadable version of Relate’s Notice of Privacy Practices.

---

Rights and Responsibilities

Non-discrimination Notice: Relate Counseling Center does not discriminate on the basis of race, color, national origin, sex, age, or disability. We provide accommodation for people with disabilities in a timely manner and free of charge when they are needed to perform services. Relate provides language assistance services for people with limited English proficiency, also free of charge. Please alert us if you would benefit from any accommodation.    

If you have any concerns about our policies, please contact the Human Resources Director at Relate Counseling Center by calling 951-932-7277. You may also file a complaint with the Office for Civil Rights by email: OCRformsubmissions.dot@state.mn.us or phone: 651-366-3073.  

Client Rights  

As a client of Relate, you have the right to know the professional qualifications of the therapist to whom you are assigned.  

You have the right to discuss with your therapist possible outcomes and side effects of any treatment you receive (including prescribed medications), and an estimate of the predicted length, cost, goals, and outcome of treatment, as well as alternative options to that treatment.  

You are expected to be on time for appointments, to participate actively in the therapy process, and to give feedback to your therapist about your progress in therapy.  

You have the right to ask your therapist about any results or interpretations of psychological testing that you complete here.  

MINORS: If you are a minor (under 18 years of age), you have the right to request, in writing, that information in your records not be shown to your parents or guardians. You will need to state what information you don’t want shown to them and why you are requesting this. If Relate agrees that it would not be in your best interest for your parents or guardians to be given this information, it will not be shown to or shared with them.  

Client Financial Responsibilities  

It is your responsibility to understand what services are covered under your insurance or other third-party payor. If you have questions, we will be happy to give you the information your insurance company has quoted, however insurance companies do not guarantee payment over the phone. Coverage is determined at the time a claim is submitted.  

It is your responsibility to inform the billing office or your therapist immediately if anything changes with your insurance or with your financial situation. Failure to provide insurance/financial information, or other requested financial information, make agreed upon payments and/or not showing up for your scheduled appointments could result in Relate terminating services and giving you options to other mental health providers outside of our agency.  

It is your responsibility to make your payment at the time of your appointment(s).  

You are expected to give at least 24 hours advance notice if you must cancel your appointment or a fee will be charged. This fee is not billable to insurance, and is the clients’ responsibility. Multiple missed appointments could result in termination of services.  

Staff Rights/Responsibilities  

Your therapist can be contacted during their regular hours. Administrative staff are available to take phone calls during regular business hours. If you are experiencing a crisis, our staff or phone greeting can provide resources for you to contact immediately.  

Your therapist has the right to refuse a form of treatment that you may request if he/she believes it is not in your best interest, or if some other conflict of interest exists.  

Your therapist has the right to terminate treatment with you, and make appropriate referrals to other resources, if he/she judges that you are not benefiting from treatment here.  

Your therapist has a responsibility to be ethical in the provision of your professional services, to be on time for appointments, to follow Center procedures, and to refer you to another therapist if he/she cannot provide services you require.  

Click Here for downloadable version of Rights and Responsibilities document.