The Health Insurance Portability and Accountability Act (HIPAA) and Client Privacy Statement
This notice describes how your medical information may be used and disclosed and how you can get access to this information. Please review it carefully.
Federal and state privacy and medical records laws protect your rights as a client of Red Lake Band of Chippewa Indian's Tribal Programs. This notice applies to your current contact with Red Lake Band of Chippewa Indian's Tribal Programs and all future contacts, whether the contact is in person, by telephone, by mail, or electronic communication.
Red Lake Band of Chippewa Indian's Tribal Programs is required to protect the privacy of your Protected Health Information (PHI). Red Lake Band of Chippewa Indian's Tribal Programs are also required by the Health Insurance Portability and Accountability Act (HIPAA) to provide you with a notice of our legal duties and privacy practices with respect to PHI. The terms you and your, refer to Red Lake Band of Chippewa Indian's Tribal Programs clients.
NOTICE INFORMATION
This Notice of Privacy Practices describes how Red Lake Band of Chippewa Indian's Tribal Programs may use and disclose your PHI to carry out treatment, payment, and health care operations and for other purposes that are specified by law.
Red Lake Band of Chippewa Indian's Tribal Programs reserve the right to change this Notice. The changes will apply for PHI Red Lake Band of Chippewa Indian's Tribal Programs already have about you and PHI Red Lake Band of Chippewa Indian's Tribal Programs receive about you in the future. Red Lake Band of Chippewa Indian's Tribal Programs will provide an updated Notice to you when you request one.
If you have questions about this Notice, Red Lake Band of Chippewa Indian's Tribal Programs privacy practices, or Red Lake Band of Chippewa Indian's Tribal Programs that this Notice applies to, please contact Red Lake Band of Chippewa Indian's Tribal Programs at:
Economic Development & Planning HIPAA Coordinator
15484 Migizi Drive
Red Lake, MN 56671 218-679-3341
PROTECTED HEALTH INFORMATION
Protected Health Information (PHI) is:
- Information about your physical or mental health, related health care services.
- Information that is provided by you, created by Red Lake Band of Chippewa Indian's Tribal Programs, or shared with Red Lake Band of Chippewa Indian's Tribal Programs by related organizations.
- Information that identifies you or could be used to identify you, such as demographic information, address and phone number, social security number, age, date of birth, dependents, and health history.
HOW RED LAKE BAND OF CHIPPEWA INDIAN'S TRIBAL PROGRAMS PROTECTS YOUR PHI
Except as described in this Notice or specified by law, Red Lake Band of Chippewa Indian's Tribal Programs will not use or disclose your PHI. Red Lake Band of Chippewa Indian's Tribal Programs will use reasonable efforts to request, use, and disclose the minimum amount of PHI necessary.
Whenever possible, Red Lake Band of Chippewa Indian's Tribal Programs will de-identify or encrypt your personal information so that you cannot be personally identified. Red Lake Band of Chippewa Indian's Tribal Programs has put physical, electronic, and procedural safeguards in place to protect your PHI and comply with federal and state laws.
YOUR RIGHTS
You have the following rights with respect to your PHI.
Obtain a copy of this Notice.
You may obtain a copy of the Notice at any time. Even if you have agreed to receive the Notice electronically, you are still entitled to a paper copy.
Request restrictions.
You may ask Red Lake Band of Chippewa Indian's Tribal Programs not to use or disclose any part of your PHI. Your request must be in writing and include what restriction(s) you want and to whom you want the restriction(s) to apply. Red Lake Band of Chippewa Indian's Tribal Programs will review and grant reasonable requests, but Red Lake Band of Chippewa Indian's Tribal Programs are not required to agree to any restrictions.
Inspect and copy.
You have the right to inspect and get a copy of your PHI for as long as Red Lake Band of Chippewa Indian's Tribal Programs maintains the information. You must put your request in writing. Red Lake Band of Chippewa Indian's Tribal Programs may charge you for the costs of copying, mailing, or other supplies that are necessary to grant your request.
Red Lake Band of Chippewa Indian's Tribal Programs has the right to deny your request to inspect and copy. If you are denied access, you may ask Red Lake Band of Chippewa Indian's Tribal Programs to review the denial.
Request amendment.
If you feel that your PHI is incomplete or incorrect, you may ask Red Lake Band of Chippewa Indian's Tribal Programs to amend it. You may ask for an amendment for as long as Red Lake Band of Chippewa Indian's Tribal Programs maintains the information. Your request must be in writing, and you must include a reason that supports your request. In certain cases, Red Lake Band of Chippewa Indian's Tribal Programs may deny
your request. If Red Lake Band of Chippewa Indian's Tribal Programs deny your request for amendment, you have the right to file a statement of disagreement with Red Lake Band of Chippewa Indian's Tribal Programs decision.
Receive a list (an accounting) of disclosures.
You have the right to receive a list of the disclosures (an accounting) that Red Lake Band of Chippewa Indian's Tribal Programs has made of your PHI on or after April 14, 2003.
The list will not include disclosures that Red Lake Band of Chippewa Indian's Tribal Programs is not required to track, such as disclosures for the purposes of treatment, payment, or health care operations; disclosures which you have authorized Red Lake Band of Chippewa Indian's Tribal Programs to make; disclosures made directly to you or to friends or family members involved in your care; or disclosures for notification purposes.
Your right to receive a list of disclosures may also be subject to other exceptions, restrictions, and limitations.
Your request for an accounting must be made in writing and state the time period for which you would like Red Lake Band of Chippewa Indian's Tribal Programs to list the disclosures. Red Lake Band of Chippewa Indian's Tribal Programs will not include disclosures made more than six years prior to the date of your request, or disclosures made prior to April 14, 2003.
You will not be charged for the first disclosure list that you request, but you may be charged for additional lists provided within the same 12-month period as the first.
Request confidential communication.
You may ask Red Lake Band of Chippewa Indian's Tribal Programs to communicate with you using alternative means or alternative locations. For example, you may ask Red Lake Band of Chippewa Indian's Tribal Programs to contact you about medical records only in writing or at a different address than the one in your file. Your request must be made in writing and state how and when you would like to be contacted.
You do not have to tell Red Lake Band of Chippewa Indian's Tribal Programs why you are making the request, but Red Lake Band of Chippewa Indian's Tribal Programs may require you to make special arrangements for payment or other communications.
Red Lake Band of Chippewa Indian's Tribal Programs will review and grant reasonable requests, but Red Lake Band of Chippewa Indian's Tribal Programs is not required to agree to any restrictions.
Note: Special Rules for Psychotherapy Notes.
Only psychotherapy notes collected by a psychotherapist during a counseling session are considered PHI. If those notes are kept separate from a client's medical records, HIPAA requires that they be treated with higher standards or protection than other PHI.
It is not Red Lake Band of Chippewa Indian's Tribal Programs practice to keep psychotherapy notes as defined by HIPAA, or to keep any client notes separate from the client's file.
WHEN RED LAKE BAND OF CHIPPEWA INDIAN'S TRIBAL PROGRAMS MAY USE AND DISCLOSE PHI
Common reasons for Red Lake Band of Chippewa Indian's Tribal Programs use and disclosure of PHI include:
Tribal Sponsorship.
Red Lake Band of Chippewa Indian's is the legal owner of the program you are being admitted to. We will be your service provider and will manage all aspects of your care. All patient documentation will be transmitted from us into the tribe's electronic health record and submitted to Medicaid for reimbursement.
Treatment.
To provide, coordinate, or manage health care and related services for you to make sure you are receiving appropriate and effective care.
For example, Red Lake Band of Chippewa Indian's Tribal Programs may contact you to provide appointment reminders, information about treatment alternatives, or to refer you to other health-related benefits and services that may be of interest to you. Or Red Lake Band of Chippewa Indian's Tribal Programs might contact another health care provider or third party to share information or consult with them about the services Red Lake Band of Chippewa Indian's Tribal Programs is providing to you.
Payment.
To obtain payment or reimbursement for services provided to you. For example, Red Lake Band of Chippewa Indian's Tribal Programs may need to disclose PHI to determine eligibility for treatment or claims payment.
Health Care Operations.
To assist in carrying out administrative, financial, legal, and quality improvement activities necessary to run Red Lake Band of Chippewa Indian's Tribal Programs business and to support the core functions of treatment and payment.
Health Plan Sponsor.
Red Lake Band of Chippewa Indian's Tribal Programs may disclose PHI to a group health plan administrator, which may, in turn, disclose such PHI to the group health plan sponsor, solely for purposes of administering benefits
Individuals involved in your care or payment for your care.
Red Lake Band of Chippewa Indian's Tribal Programs may disclose your PHI to a family member, other relative, close personal friend, or any person you identify, who is, based on your judgment, believed to be involved in your care or in payment related to your care.
As required by law.
Red Lake Band of Chippewa Indian's Tribal Programs must disclose PHI when required to do so by law.
LESS COMMON REASONS FOR RED LAKE BAND OF CHIPPEWA INDIAN'S TRIBAL PROGRAMS USE AND DISCOSURE OF PHI INCLUDE:
Legal proceedings.
Red Lake Band of Chippewa Indian's Tribal Programs may disclose PHI for a judicial or administrative proceeding in response to a court order, written notice, or protective order.
To avert serious threat to public health or safety.
Red Lake Band of Chippewa Indian's Tribal Programs may disclose PHI to avoid a serious and imminent threat to your health or safety or to the health or safety of others.
To provide reminders and benefits information to you.
Disclosures may be used to verify your eligibility for health care and enrollment in various health plans and to assist Red Lake Band of Chippewa Indian's Tribal Programs in coordinating benefits for those who have other health insurance or eligibility for government benefit programs
Worker's compensation.
Red Lake Band of Chippewa Indian's Tribal Programs may disclose PHI to comply with worker's compensation laws and other similarly legally established programs.
Abuse or neglect.
Red Lake Band of Chippewa Indian's Tribal Programs may make disclosures to government authorities or social service agencies as required by law in the reporting of abuse, neglect, or domestic violence.
To government agencies for compliance purposes.
Red Lake Band of Chippewa Indian's Tribal Programs may use or disclose PHI to the Secretary of Health and Human Services to assist with a complaint investigation or compliance review.
Law enforcement.
Red Lake Band of Chippewa Indian's Tribal Programs may disclose PHI to law enforcement officials for the purpose of identifying or locating a suspect, witness, or missing person, or to provide information about victims of crimes.
Your written permission:
Red Lake Band of Chippewa Indian's Tribal Programs is required to get your written permission (authorization) before using or disclosing your PHI for purposes other than those provided above, including use or disclosure of PHI for marketing purposes and sale of PHI, or as otherwise permitted or required by law. If you do not want to authorize a specific request for disclosure, you may refuse to do so without fear of reprisal.
You may withdraw your permission:
If you do provide your written authorization and then later want to withdraw it, you may do so in writing at any time. As soon as Red Lake Band of Chippewa Indian's Tribal Programs receives your written revocation, Red Lake Band of Chippewa Indian's Tribal Programs will stop using or disclosing the PHI specified in your original authorization, except to the extent that Red Lake Band of Chippewa Indian's Tribal Programs has already used it based on your written permission.
YOU MAY FILE A COMPLAINT
If you believe your privacy rights have been violated, you can file a complaint with Red Lake Band of Chippewa Indian's Tribal Programs HIPAA Privacy Officer, or with the United States Department of Health and Human Services at:
Medical Privacy Complaint Division
Office for Civil Rights
U.S. Department of Health and Human Services 200 Independence Avenue, SW
Room 509F, HHH Building
Washington, DC 20201
1-800-368-1019
DATA PRIVACY
Why does Red Lake Band of Chippewa Indian's Tribal Programs ask for information?
Red Lake Band of Chippewa Indian's Tribal Programs asks for information from you to determine what service or help you need, develop a service plan with you, and give you the services you want.
The information may also be used to determine your charges for services or for collection of payment from insurance companies or other payment sources.
Do you have to give information to Red Lake Band of Chippewa Indian's Tribal Programs?
There is no law that says you must give Red Lake Band of Chippewa Indian's Tribal Programs any information. However, if you choose to not give Red Lake Band of Chippewa Indian's Tribal Programs some information, it can limit Red Lake Band of Chippewa Indian's Tribal Programs ability to serve you well.
What will happen if you do not answer the questions Red Lake Band of Chippewa Indian's Tribal Programs asks?
If you are here because of a court order, and you refuse to provide information, that refusal may be communicated to the Court.
Without certain information, Red Lake Band of Chippewa Indian's Tribal Programs may not be able to tell who should pay for your services.
WHAT PRIVACY RIGHTS DO MINORS HAVE?
If you are under 18, you may request that information about you be kept from your parents. You must give Red Lake Band of Chippewa Indian's Tribal Programs your request in writing, describe the information, and tell Red Lake Band of Chippewa Indian's Tribal Programs why you don't want your parents to see it.
If, after reviewing your request, your therapist at Red Lake Band of Chippewa Indian's Tribal Programs believes that giving information to your parents is not in your best interest, Red Lake Band of Chippewa Indian's Tribal Programs will not share the information. If your therapist believes this information could be safely shared with your parents, Red Lake Band of Chippewa Indian's Tribal Programs will inform you of that decision.
If you are 14, you may ask for mental health services without the consent of your parents, but you may have to pay for the services if you do not want your parents to know.
By signing this form your signature shows that Red Lake Band of Chippewa Indian's Tribal Programs has informed you of your privacy rights, that you are aware of the possible uses and disclosures of your protected health information and that you have received a copy of this information
SELF ATTESTATION OF NATIVE AFFILIATION
I {name} attest that I am an enrolled member, a descendant of an enrolled member, or a non-Indian eligible for Indian Health Services. This has been determined by the statute below:
2-1.2 PERSONS ELIGIBLE FOR IHS HEALTH CARE SERVICES. A person may be regarded as eligible and within the scope of the IHS health care program if he or she is not-otherwise excluded by provision of law, and is:
A. American Indian and/or Alaska Native. American Indian and/or Alaska Native (AI/AN) descent and belongs to the Indian community served by the IHS program, as evidenced by such factors as:
- Membership, enrolled or otherwise, in an AI/AN Federally-recognized Tribe or Group under Federal supervision.
- Resides on tax-exempt land or owns restricted property
- Actively participates in tribal affairs.
- Any other reasonable factor indicative of Indian descent.
- In case of doubt that an individual applying for care is within the scope of the program, as established in 42 C.F.R. § 136.12(b), and the applicant's condition is such that immediate care and treatment are necessary, services shall be provided pending identification as an Indian beneficiary.
B. Eligible Non-Indians. Care and treatment of non-Indians shall be provided, in accordance with 25 U.S.C. § 1680c, 42 C.F.R. §§136.12, and 136.14, as follows:
- Children. Any individual who has not attained 19 years of age; is the natural or adopted child, stepchild, foster child, legal ward, or orphan of an eligible Indian; and is not otherwise eligible for health services provided by the IHS, shall be eligible for all health services provided by the IHS on the same basis and subject to the same rules that apply to eligible Indians until such individual attains 19 years of age. The existing and potential health needs of all such individuals shall be taken into consideration by the IHS in determining the need for, or the allocation of, the health resources of the IHS. If such an individual has been determined to be legally incompetent prior to attaining 19 years of age, such individual shall remain eligible for such services until 1 year after the date of a determination of competency [25 U.S.C. §1680c (a)].
- Spouses. Any spouse, including a same-sex spouse, of an eligible Indian who is not an Indian, or who is of Indian descent but is not otherwise eligible for the health services provided by the IHS, shall be eligible for such health services if the governing body of the Indian Tribe or Tribal Organization providing such services deem them eligible by an appropriate resolution as a class. The health needs of persons made eligible under this paragraph shall not be taken into consideration by the IHS in determining the need for, or allocation of, its health resources [25 U.S.C. §1680c (b)].
- A non-Indian woman pregnant with an eligible Indian's child for the duration of her pregnancy, and through post- partum (usually 6 weeks after delivery) (42 U.S.C. § 136.12). In cases where the woman is not married to the eligible Indian under applicable law or tribal law, paternity must be acknowledged by either:
- The eligible Indian, in writing.
- Determined by order of a court of competent jurisdiction.
- A non-Indian member of an eligible Indian's household and the medical officer in charge determines that services are necessary to control a public health hazard or an acute infectious disease, as stated in 42 C.F.R. § 136.12(a).
- Other non-Indian beneficiaries are described in Part 2, Chapter 4 of the IHM, such as non-Indian employees and veterans, whom may also be authorized for limited services, as described in Part 2, Chapter 4 of the IHM.
RELEASE OF INFORMATION FOR MEDICAL BILLING DATA
I {name} authorize Red Lake Band of Chippewa Indian's Tribal Programs and its affiliates, its employees and agents, to exchange my personal health information (e.g., information relating to the diagnosis, treatment, claims payment, and health care services provided or to be provided to me which identifies my name, address, Social Security number, member ID number) except the following information about me with any third-party payer having responsibility for payment of charges for treatment for the purpose of helping me to resolve claims and health benefit coverage issues. I understand that any personal health information or other information released to the person or organization identified above may be subject to re-disclosure by such person/organization and may no longer be protected by applicable federal and state privacy laws.
Patient Restrictions on Methods for Disclosure:
I understand that communication of the items can occur:
- Verbally
- In person conference
- Written questionnaire
- Mailed or faxed medical record/correspondence
I understand that:
- My health information is protected by federal regulation (Alcohol and Drug Abuse Patient Records, 42 CFR Part 2: and/or HIPAA 45 CFR) and state privacy laws, and disclosure is allowed only with my authorization except in limited circumstances described in Red Lake Band of Chippewa Indian's Tribal Programs Privacy Notice. I understand that I have a right to inspect and receive a copy of my treatment records that may be disclosed to others, as provided under applicable state and federal laws.
- I can revoke this authorization at any time except to the extent that action has been taken in reliance on it. Red Lake Band of Chippewa Indian's Tribal Programs Privacy Notice outlines the procedure for revocation. This authorization will expire in one year from the date I sign or unless I request an earlier expiration in writing.
- For disclosures other than for treatment, payment and healthcare operations purposes, treatment may not be conditioned on my agreement to sign and authorization (unless I am receiving care solely to create protected health information for disclosure to a third party) (45 CFR & 164.508 (b)(4)(III)
- Communications resulting from this authorization will reveal that I receive services at Red Lake Band of Chippewa Indian's Tribal Programs.
- Federal confidentiality regulations (at 42 CFR Part 2) prohibit re-disclosure of information from alcohol and drug abuse patient records. However, HIPAA requires Red Lake Band of Chippewa Indian's Tribal Programs to notify me of the potential that information disclosed pursuant to this authorization might be re-disclosed by the recipient and is no longer protected by HIPAA rules.
- This authorization may be used by Red Lake Band of Chippewa Indian's Tribal Programs owned or managed programs upon transfer of my care to them.