As required by the privacy regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)

THIS NOTICE DESCRIBES HOW PROTECTED MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

1. Gateway Family Health Clinic Ltd is permitted to make uses and disclosures of protected health information (PHI) for treatment, payment, and health care operations, as described in the following examples:
a. For treatment – which includes the provision, coordination, or management of health care and related services by one or more health care providers, etc. Example: We may use your protected health information in order to write a prescription for you and we may disclose that PHI to a pharmacy when we order a prescription for you. Our physicians, nurses and staff may use or disclose your PHI in order to treat you or to assist others in your treatment. We may also disclose your PHI to other health care providers for purposes related to your treatment. 
b. For payment – which includes activities undertaken by the practice to obtain or provide reimbursement for the provision of health care, including but not limited to: determination or eligibility or coverage; billing, claims management, or to entities to assist in collection efforts. Example: It is necessary to provide PHI on the insurance claim form we submit on your behalf to your insurance carrier. 
c. For healthcare operations – which includes the conduction of quality assessment and improvement activities, performing internal audits and facilitating compliance programs, etc. Example: we may use your protected health information to evaluate the quality of health care services that were performed for you.

2. Gateway Family Health Clinic Ltd is permitted or required under law, in specific circumstances, to use or disclose protected health information without the individual’s written authorization, such as in the case of public health reporting purposes, emergencies, and subject to certain requirements for auditing purposes, research studies, law enforcement purposes, judicial and administrative proceedings.

3. Any other uses and disclosures will be made only with the Individual’s written authorization, and the individual may revoke such authorization.

4. Gateway Family Health Clinic Ltd intends to engage in the following activity:
a. Gateway Family Health Clinic Ltd may contact the individual to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that maybe of interest to the individual or patient.

5. The individual has the following rights regarding protected health information:
a. The right to request restrictions on certain uses and disclosures of PHI. Gateway Family Health Clinic Ltd is not required to agree to a requested restriction, however.
b. The right to receive confidential communications of PHI, as applicable.
c. The right to inspect and copy protected health information, as provided in the Privacy Regulation.
d. The right to amend protected health information, as provided in the Privacy Regulation.
e. The right to receive an accounting of disclosures of protected health information.
f. The right to obtain a paper copy of the Notice from the covered entity upon request. This right extends to an individual who has agreed to receive the Notice electronically. 

6. Gateway Family Health Clinic Ltd is required by law to maintain the privacy of protected health information and to provide individuals with notice of its legal duties and privacy practices with respect to protected health information.

7. Gateway Family Health Clinic Ltd is required to abide by the terms of the Notice currently in effect.

8. Gateway Family Health Clinic Ltd reserves the right to change the terms of this Notice. The new Notice provisions will be effective for all protected health information that it maintains.

9. Gateway Family Health Clinic Ltd will provide individuals or patients with a revised Notice by distribution at time of service at the clinic location. Privacy practice information is available at our web site at www.gatewayclinic.com. 

10. Individuals may complain to the Gateway Family Health Clinic Ltd by contacting the Privacy Officer or Administrator as listed below or to the Secretary of the Department of Health and Human Services, without fear of retaliation by the organization, if they believe their privacy rights have been violated. 

(A) Clinic Manager/Privacy Officer 1-218-485-2001 or:
(B) Administrator 1-218-485-2000
Address: 4570 County Highway 61, Moose Lake, MN 55767
(C) Secretary of the US Department of Health and Human Services,
Medical Privacy Complaint Division
Region V, Office for Civil Rights, U.S. Dept. of Health and Human Services, 233 N. Michigan Ave., Suite 240, Chicago, IL  60601, Voice - (312) 886-2359, FAX - (312) 886-1807, TDD - (312) 353-5693, E-mail - OCRComplaint@hhs.gov

11. Gateway Family Health Clinic Ltd elects to limit the uses or disclosures that it is permitted to make, as follows: Only as permitted or required by law such as for the purpose of treatment, payment and health care operations and only that which we feel is needed for a specific purpose.