Data Privacy

SOUTHWEST HEALTH AND HUMAN SERVICES

YOUR PRIVACY RIGHTS

Ag#009 05 13

DHS 3979 (Effective Date: August 2011)

This notice tells how medical and other private information about you may be used and disclosed and how you can get this information. Please review it carefully

Why do we ask for this information?

  • To tell you apart from other people with the same or similar name
  • To decide what you are eligible for
  • To help you get medical, mental health, financial or social services and decide if you can pay for some services
  • To make reports, do research, do audits, and evaluate our programs
  • To investigate reports of people who may lie about the help they need
  • To decide about out-of-home care and in-home care for you or your children
  • To collect money from other agencies, like insurance companies, if they should pay for your care
  • To decide if you or your family need protective services
  • To collect money from the state or federal government for help we give you.

Why do we ask you for your Social Security number?

We need your Social Security number (SSN) to give you medical assistance, some kinds of financial help, or child  support enforcement services (42 CFR 435.910 [2006]; Minn. Stat. 256D.03, subd.3(h); Minn. Stat.256L.04, subd. 1a; 45 CFR 205.52 [2001]; 42 USC 666; 45 CFR 303.30 [2001]). We also need your SSN to verify identity and prevent duplication of state and federal benefits. Additionally, your SSN is used to conduct computer data matches with collaborative, nonprofit and private agencies to verify income, resources, or other information that may affect your eligibility and/or benefits.
You do not have to give us the SSN:

  • For persons in your home who are not applying for coverage
  • If you have religious objections
  • If you are not a U.S. citizen and are applying for Emergency Medical Assistance only
  • If you are from another country, in the U.S. on a  temporary basis and do not have permission from the U.S. Citizenship and Immigration Services (USCIS) to live in the U.S. permanently
  • If you are living in the U.S. without the knowledge or approval of the USCIS.

Do you have to answer the questions we ask?

You do not have to give us your personal information. Without the information, we may not be able to help you. If you give us wrong information on purpose, you can be investigated and charged with fraud.

With whom may we share information?

We will only share information about you as needed and as allowed or required by law. We may share your information with the following agencies or persons who need the information to do their jobs:

  • Employees or volunteers with other state, county, local, federal, collaborative, nonprofit and private agencies
  • Researchers, auditors, investigators, and others who do quality of care reviews and studies or commence prosecutions or legal actions related to managing the human services programs.
  • Court officials, county attorney, attorney general, other law enforcement officials, child support officials, and child protection and fraud investigators
  • Human services offices, including child support enforcement offices
  • Governmental agencies in other states administering public benefits programs
  • Health care providers, including mental health agencies and drug and alcohol treatment facilities
  • Health care insurers, health care agencies, managed care organizations and others who pay for your care
  • Guardians, conservators or persons with power of attorney
  • Coroners and medical investigators if you die and they investigate your death
  • Credit bureaus, creditors or collection agencies if you do not pay fees you owe to us for services
  • Anyone else to whom the law says we must or can give the information.

We may disclose your health information to a record locator service. This can help health care providers find health plans and other health care providers that have health information about you. The health care provider can then get that information to help make better decisions about your treatment. If you prefer not to be included in the record locator service, you may “opt out” by contacting the Community Health Information Collaborative (CHIC) service desk at (877) 411-CHIC (toll free), 218-625-5515 (voice), 218-625-5518 (fax).

What are your rights regarding the information we have about you?

  • You and people you have given permission to may see and copy medical or other private information we have about you. You may have to pay for the copies.
  • You may question if the information we have about you is correct. Send your concerns in writing. Tell us why the information is wrong or not complete. Send your own explanation of the information you do not agree with. We will attach your explanation any time information is shared with another agency.
  • You have the right to ask us in writing to share health information with you in a certain way or in a certain place.

For example, you may ask us to send health information to your work address instead of your home address. If we find that your request is reasonable, we will grant it.

  • You have the right to ask us to limit or restrict the way that we use or disclose your information, but we are not required to agree to this request.
  • You have the right to get a record of some of the people or organizations with whom we have shared your information. This record was started on April 14, 2003. You must ask for a copy of this record in writing to our Privacy Official.
  • If you do not understand the information, ask your worker to explain it to you. You can ask the Minnesota Department of Human Services for another copy of this notice.

What are our responsibilities?

  • We must protect the privacy of your medical and other private information according to the terms of this notice.
  • We may not use your information for reasons other than the reasons listed on this form or share your information with individuals and agencies other than those listed on this form unless you tell us in writing that we can.
  • We must follow the terms of this notice, but we may change our privacy policy because privacy laws change. We will put changes to our privacy rules on our website at:

http://edocs.dhs.state.mn.us/lfserver/

Public/DHS-3979-ENG

What privacy rights do children have?

If you are under 18, when parental consent for medical treatment is not required, information will not be shown to parents unless the health care provider believes not sharing the information would risk your health. Parents may see other information about you and let others see this information, unless you have asked that this information not be shared with your parents. You must ask for this in writing and say what information you do not want to share and why. If the agency agrees that sharing the information is not in your best interest, the information will not be shared with your parents. If the agency does not agree, the information may be shared with your parents if they ask for it.

What if you believe your privacy rights have been violated?

You may complain if you believe your privacy rights have been violated. You cannot be denied service or treated badly because you have made a complaint. If you believe that your medical privacy was violated by your doctor or clinic, a health insurer, a health plan, or a pharmacy, you may send a written complaint either to the county agency, the organization or to the federal civil rights office at:

U.S. Department of Health and Human Services
Office for Civil Rights, Region V
233 N. Michigan Avenue, Suite 240
Chicago, IL 60601
(312) 886-2359 (Voice) or
toll free (800) 368-1019 or (866) 282-0659
(312) 353-5693 (TTY)
(312) 886-1807 (Fax)

If you think that the Minnesota Department of Human Services has violated your privacy rights, you may send a written complaint to the U.S. Department of Health and Human Services at the address above or to:

Dale Hiland, Privacy Officer
Southwest Health and Human Services
607 West Main Street, Suite 100
Marshall, MN  56258

Or

Carol Biren, Privacy Officer
Southwest Health and Human Services
607 West Main Street, Suite 200
Marshall, MN  56258

Or

Minnesota Department of Human Services
Attn: Privacy Official
PO Box 64998
St. Paul, MN 55164-0998

We cannot deny you services or treat you badly because you have filed a complaint against us.

Sign below to indicate that you have received this privacy notice.

________________________________________________________                             _______________________________

Client Signature or Guardian                                                                                                                            Date

This information is available in other forms to people with disabilities by contacting us at 651/296-8517 (voice),

Toll free at 1-800-657-3659.  TDD users can call the Minnesota Relay at

1-800-627-3529 (TDD), 7-1-1 or 1-877-627-3848 (speech to speech relay service).