Your Information. Your Rights. Our Responsibilities.
Suburban Radiologic Consultants / Suburban Imaging (“Suburban”) is committed to safeguarding your medical information. This notice describes how medical information (known as “Protected Health Information” or “PHI”) about you may be used and disclosed and how you can get access to this information. Please review it carefully.
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Receive an electronic or paper copy of your medical record
• You can ask to see or copy an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
• We will provide a copy or a summary of your health information within a reasonable time.
Ask us to correct your medical record
• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
• We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request for us to contact you confidentially
• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
• We will say “yes” to all reasonable requests.
Ask us to limit what we use or share
• You can ask us not to use or share certain health information for treatment, payment, or our operations (TPO). We are not required to agree to your request, and we may say “no” if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
Choose someone to act for you
• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
Get a list of those with whom we’ve shared information
• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free, but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
File a complaint if you feel your rights are violated
• You can complain if you feel we have violated your rights by contacting us using the information at the bottom of this notice.
• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to: 200 Independence Avenue, S.W., Washington, D.C. 20201; calling 1-877-696-6775; or visiting: www.hhs.gov/ocr/privacy/hipaa/complaints/
• We will not retaliate against you for filing a complaint.
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information with your family, close friends, or others involved in your care, please tell us what you want us to do, and we will follow your instructions.
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases, we will never share your information unless you sign a written authorization:
• Marketing purposes
• Sale of your information
• For any other purpose that is not defined below
How do we typically use or share your health information?
We typically use or share your health information in the following ways. We need your consent before we disclose protected health information for treatment, payment, and operations purposes, unless the disclosure is to a related entity, or the disclosure is for a medical emergency and we are unable to obtain your consent due to your condition or the nature of the medical emergency. We ask you to review and sign this consent form annually, however you may revoke consent in writing at any time.
We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Run our organization
We can use and share your health information to run our practice, improve your care, and contact you when necessary.
Example: We use health information about you to manage your treatment and services.
Bill for your services
We can use and share your health information to bill and get payment from health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your services.
How else can we use or share your health information?
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html
Help with public health and safety issues
We can share health information about you for certain situations such as:
• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone’s health or safety
We can use or share your information for health research if you do not object.
Comply with the law
We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
Work with a medical examiner or coroner
We can share health information with a coroner and medical examiner when an individual dies.
Address workers’ compensation, law enforcement, and other government requests
We can use or share health information about you:
• For workers’ compensation claims
• For law enforcement purposes or with a law enforcement official with your consent, unless required by law
• With health oversight agencies for activities authorized by law
• For special government functions such as military, national security, and presidential protective services with your consent, unless required by law.
Respond to lawsuits and legal actions
We can share health information about you in response to a court or administrative order, or in response to a subpoena.
Maintain privacy and security
We are required by law to maintain the privacy and security of your protected health information.
Inform of breach
We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
Follow Notice of Privacy Practices
We must follow the duties and privacy practices described in this notice and give you a copy of it.
We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html
Changes to the terms of this notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.
Effective Date of this Notice: April 1, 2018
Name and Contact of Privacy Official
Attention: Compliance Officer
2355 Highway 36 West
Roseville, MN 55113
Entities covered by this notice
Suburban Imaging uses a shared electronic PACS (Picture Archiving and Communication System) that allows care providers of other healthcare entities to access your images and reports via a secure electronic portal. They may do so as needed at the time you are seeking care, even if they work at different hospitals and clinics. We require a signed agreement by the healthcare providers and/or the organization they work for to only use your information for purposes covered by the privacy law. We do this so it is easier for your providers to access your imaging records and provide coordination of your healthcare needs. You may contact us for a list of these entities.