Notice of Medical Privacy Practices


PLEASE REVIEW IT CAREFULLY. You may download a PDF version of this document by clicking here.

Protected Health Information.

While receiving care from our facility, information regarding your medical history, treatment, and payment for your health care may be originated and/or received  by us.  Information which  can be used to identify you and  which  relates to your past, present or future medical condition, receipt of health care  or payment for health care  (“Protected Health Information”).

How Your Information Is Maintained.

Information may be maintained by the facility in a variety of ways.   This may include paper documents, electronic documents, data tapes and images of various types as well as the use of email, secure messaging systems, electronic systems, the internet, cloud providers and participation in third-party networks such as the Iowa Health Information Network.

Our Responsibilities.

Federal law imposes certain obligations and duties upon us as a covered health care provider with respect to your Protected Health Information.  Specifically, we are required to:

Provide you with notice of our legal duties and our facility’s policies regarding the use and disclosure of your Protected Health Information;

  • Maintain the confidentiality of your Protected Health Information in accordance with state and federal law;
  • Honor  your  requested restrictions regarding the  use and  disclosure of your  Protected Health Information unless under the  law we are authorized or required to release your  Protected Health Information without your  authorization, in which  case you will be notified  within a reasonable period  of time  as allowed  by law;
  • Allow you to inspect and copy your Protected Health Information during our regular business hours;
  • Act on your  request to amend Protected Health Information within sixty  (60) days  and  notify you of any delay  which  would  require us to extend the  deadline by the  permitted thirty (30) day extension;
  • Accommodate reasonable requests to communicate Protected Health
    Information by alternative means or methods; and
  • Abide by the terms of this notice.

How Your Protected Health Information May be Used and Disclosed.

Generally, your Protected Health Information may be used and disclosed by us only with your express written authorization. However, there are some exceptions to this general rule.

Treatment. Payment, or Health  Care Operations.

General Use.

As part of our treatment, payment and operations we may also release information to business associates who may perform various treatment, payment or operation functions.  Information may also be exchanged, stored or listed with records locator services, record repositories, and other third-parties such as the Iowa Health Information Network. If information is provided to another person or entity, such as another facility or physician from whom you seek treatment, that facility or physician may treat the information received as part of its protected information.

Treatment Purposes.

We may use or disclose your Protected Health Information for treatment purposes. During your care at our facility, it may be necessary for various personnel involved in your care to have access to your Protected Health Information in order to provide you with quality care.   For example, we may inform dietary personnel of any condition which requires you have a special diet.   In addition, we may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services which may be of interest to you.

Situations may also arise when it is necessary to disclose your Protected Health Information to health care providers outside our facility who may also be involved in your care or to facilitate referral to another provider or care facility.  For example, we may inform your physician of medications you are currently taking, provide other information for continuity of care.

Payment Purposes.

Your Protected Health Information may also be used or disclosed for payment purposes. It is necessary for us to use or disclose Protected Health Information so that treatment and services provided by us may be billed and collected from you, your insurance company, or other third party payor.   For example, we may disclose your Protected Health Information to your health insurance carrier to obtain prior approval for a service.  We may also  release your Protected Health Information to another health care  provider or individual or entity covered  by the  HIPAA  regulations who has  a relationship with  you for their payment activities.   For example, we may disclose information to your health insurance carrier upon its request for additional information necessary for it to determine whether a service is covered.

Health Care Operations.

Your Protected Health Information may also be used for health care operations, which are necessary to ensure our facility provides the highest quality of care.   For example, your Protected Health Information may be used for quality assurance or risk management purposes or disclosed to our accountant for auditing purposes. We may at times remove information which could identify you from your record so as to prevent others from learning who the specific patients are.   In addition, we may  release your  Protected Health Information to another individual or entity covered  by the  HIPAA  privacy regulations that has  a relationship with  you for their fraud and  abuse detection or compliance purposes, quality assessment and  improvement activities, or review, evaluation or training of health care  professionals or students. For example, we may  disclose  information to another health care  provider involved in your  care  if the provider requests the  information is necessary for its evaluation of one of its medical students.  We may also release information to business associates who may perform various treatment, payment or operation functions.

Patient Directory.

Our facility maintains a patient directory.  Unless you object, your name, location in the facility, general condition, and religious affiliation will be contained in the directory.  The directory is disclosed to members of the clergy and except  for religious affiliation, to other persons who specifically ask for the information by your  name.   You are not obligated, however, in any way, to consent to the inclusion of your information in the facility directory. Please notify facility personnel if you do not wish to be included in the directory or if you wish for information or disclosure to be limited in some way.

Notification and Communications to Individuals Involved in Your Care.

Unless you have informed us otherwise, your  Protected Health Information may be used  or disclosed by us to notify or assist in notifying a family member or other person responsible for your  care.  In most cases, Protected Health Information disclosed for notification purposes will be limited to your name, location and general condition.  In addition, unless you have  informed us otherwise, Protected Health Information may  be released to a family  member, relative or close personal friend who is involved in your  care  to the  extent necessary for them  to participate in your care.   In the event you wish for any of these uses or disclosures to be limited, please contact facility personnel.

Fundraising & Marketing Activities.

We may use your Protected Health Information for the purpose of contacting you as part of a facility based fund-raising effort.   Such contact could come from the facility, an affiliated organization such as a foundation or a business associate. Information used as part of this fundraising activity may include demographic information such  as name,  address, age,  gender, date  of birth, department of service, your  treating physician, outcome  information and  your  health insurance status.  If you do not wish  to be contacted for fundraising activities you may contact Jacque Aanestad at 319-622-3195 to have  your  name  removed from  our  fundraising list  or you may do so on our website at  You may receive  information such  as prescription or refill  reminders from  the facility; however,  your  information will not be provided to third-party marketers and  the facility will not sell your  information to others for use and  marketing processes without your  specific  authorization.

Disaster Relief.

In the event of a disaster we may provide information to public or private entities as needed to facilitate treatment, locate family  members or caregivers, and  to facilitate public  health needs.

Psychotherapy Notes.

In the event psychotherapy notes are maintained as part of your health information, those notes will not be used or disclosed except in limited circumstances without your authorization. Such authorization is not needed and will not be obtained if such notes are used by the person who created them, in a reasonable training program for the facility, or as otherwise allowed by law.

Research  Purposes.

In some instances, your Protected Health Information may be used or disclosed for research purposes. All research projects which use Protected Health Information are subject to a special approval process which will, among other things, evaluate the precautions used to protect patient medical information.  In many cases, information which identifies you as the patient will be removed.

Authorized by Law.

We may also use or disclosure your protected health information without your authorization as permitted or required by law.   Examples include: public health activities, health oversight activities, judicial and administrative proceedings, abuse reporting, law enforcement, organ donation, medical examiners and coroners, workers compensation processes and research purposes.  Information will only be used/disclosed without your authorization as permitted by the applicable state or federal law.

More Stringent Laws.

Some of your Protected Health Information may be subject to other laws and regulations and afforded greater protection than what is outlined in this Notice.   For instance, HIV/AIDS, substance abuse, mental health, information and genetic information are often given more protection.  In the event your Protected Health Information is afforded greater protection under federal or state law, we will comply with the applicable law.

Other uses  and  disclosures of Protected Health Information not  covered  by this Notice or the laws that apply to us will be made only with your written permission. For example , we need  your  written authorization to disclose  your entire medical record  to a family  member (other  than personal representatives as allowed by law)  although some  information may  be disclosed  under limited circumstances without permission.  We must also have your written authorization to disclose your Protected Health Information to an attorney who represents you.  If you provide  us permission to  use  or  disclose  Protected Health  Information about you,  you  may revoke  that permission, in writing, at  any  time.   If you revoke  your  permission, we will no longer use or disclose Protected Health Information about you for the reasons covered  by your  written authorization.  You understand that we are  unable to take back any disclosures we have already made with your  permission, and  that we are  required to retain our records of the care that we provided  to you.

Your Rights.

Federal law grants you certain rights with respect to your Protected Health Information.  Specifically, you have the right to:

  • Receive notice of our policies and procedures used to protect your Protected Health Information;
  • Request that certain uses  and  disclosures of your  Protected Health Information be restricted; provided, however,  if we may release the information without your consent or authorization, we have  the  right to refuse  your  request;
  • You may restrict disclosure to a health plan of your information where you have paid the full out of pocket costs for the services rendered. This restriction would apply only to those  services where  you had  paid the  full out of pocket  costs,  it would  not apply  to other  information relating to treatment which was paid for by or submitted to an insurer;
  • Access to your Protected Health Information; provided, however, the request must be in writing and may be denied in certain limited situations;
  • Request that your Protected Health Information be amended;
  • Obtain an accounting of certain disclosures by us of your Protected Health Information for the past six years;
  • Revoke any prior authorizations or consents for use or disclosure of Protected Health Information, except to the extent that action has already been taken;
  • Request communications of your Protected Health Information are done by alternative means or at alternative locations; and
  • Notification of any breach of unsecured Protected Health Information relating to you and actions you may take in relationship to such a breach.

Important Contact Information.

This notice has been provided to you as a summary of how we will use your Protected Health Information and your rights with respect to your Protected Health Information. If you have any questions or for more information regarding your Protected Health Information, please contact Jacque Aanestad at 319-622-3195.

If you believe your privacy rights have been violated, you may file a complaint with our office by contacting Jacque Aanestad at 319-622-3195.  You may also file a complaint with the Secretary of Health and Human Services. There will be no retaliation for the filing of a complaint.  The following website: contains most reporting instructions general information regarding these matters.

Effective Date.

This notice become effective on September 9, 2013. Please note, we reserve the right to revise this notice at any time.  A current notice of our privacy practices may be obtained from our office at 3207 220th Trail Amana, IA 52203.