Notice of privacy practices

Dear Mayo Clinic Patient:

Mayo Clinic has always been a leader in protecting patients' medical information. Maintaining patient privacy is part of our mission to serve the needs of the patient first. Controlled use of medical information by staff at Mayo Clinic is essential to providing optimum patient care.

The United States government created rules for the use and protection of medical and health information by hospitals, clinics and other medical practices. The rules are a result of the 1996 Health Insurance Portability and Accountability Act (HIPAA). They are meant to provide all patients in the United States with standard privacy protections. One rule requires hospitals and clinics to provide all patients with a Notice of Privacy Practices to explain how patient medical information is used. The same rule requires hospitals and clinics to keep records showing that patients have received the notice.

We are happy to provide you with this copy of Mayo Clinic's Notice of Privacy Practices. We hope it will answer any questions you may have about how patient medical information is used here. In accordance with the federal government HIPAA rules, please sign the form that came with this notice and bring it with you to your appointment. Signing the form will show that you have received the notice; it will in no way affect the care you receive at Mayo Clinic.

If you have questions about anything contained in this notice, please feel free to contact the site privacy officer for the applicable Mayo Clinic entity. Contact information for these individuals is provided in the final section of this notice.

Thank you for placing your care, and your trust, in Mayo Clinic.

Sincerely,

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

Where this applies

This notice applies to the following Mayo Clinic entities and health care practices sites (collectively referred to as "Mayo Clinic"):

Minnesota: Mayo Clinic in Rochester, Mayo Clinic Hospital, Saint Marys Campus, Mayo Clinic Hospital, Methodist Campus, Mayo Psychiatry and Psychology Treatment Center (Generose), Mayo Foundation for Medical Education and Research, Mayo Clinic Hospice, Charter House, Mayo Clinic Pharmacy, Mayo Clinic Store, Gold Cross Ambulance Service and Mayo Clinic Medical Transport (in Minnesota and Wisconsin), the Mayo Family Practice Clinic Kasson, and the Mayo Family Clinic Northwest and Northeast.

Florida: Mayo Clinic in Jacksonville and its health care practice sites including, but not limited to, its affiliated hospital and its offsite primary care practices.

Arizona: Mayo Clinic in Arizona and its health care practice sites including, but not limited to, its hospital, outpatient clinics and off- site primary care practices (collectively referred to as "Mayo Arizona Entities").

Mayo Clinic Health System: includes operating locations in Blooming Prairie, Kenyon, MN, Albert Lea, Alden, Kiester, MN, Lake Mills, Charles City, IA, New Richland, Wells, Austin, Adams, LeRoy, Cannon Falls, Faribault, Fairmont, Lakeville, MN, Armstrong, IA, Blue Earth, Sherburn, Mabel, MN, Truman, MN, Eau Claire, Chippewa Falls, Osseo, Mondovi, Barron, Cameron, Onalaska, Chetek, Prairie Farm, WI, Prairie du Chien, WI, Waukon, IA, Bloomer, Colfax, and Rice Lake, La Crosse, Elmwood, Glenwood City, WI, Arcadia, WI, Caledonia, Farmington, MN, Red Wing, Zumbrota, Elko New Market, Northfield, MN, Ellsworth, WI, Decorah, IA, Holmen, WI, La Crescent, MN, Sparta, WI, Tomah, WI, Lake City, Montgomery, MN, Alma, WI, Plainview, MN, Wabasha, Mankato, Janesville, New Prague, Lake Crystal, Lonsdale, Lamberton, Springfield, Le Sueur, St. James, St. Peter, Trimont, Waseca, Waterville, Belle Plaine, MN, Menomonie, WI, and Owatonna, MN, and Waycross, GA, Northwest Health Ventures, Inc., d/b/a Midelfort Pharmacy & Home Medical, Northwest Wisconsin HomeCare, Inc., Northwest Wisconsin Supportive HomeCare, Inc., WI.

Mayo Clinic's duties

By law, Mayo Clinic must keep protected health information private. The federal government defines protected health information as any information, whether oral, electronic or paper, which is created or received by Mayo Clinic and relates to a patient's physical or mental health or condition, or payment for the provision of medical services. This includes not only the results of tests and notes written by doctors, nurses and other clinical personnel, but also certain demographic information (such as your name, address and telephone number) that is related to your health records.

Mayo Clinic is required by law to give you this notice and to follow the terms and conditions of the notice that is currently in effect. Mayo Clinic will report breaches of your unsecured protected health information as required by law.

How Mayo Clinic fulfills these duties

  • Mayo Clinic considers patient privacy as part of its mission to serve the needs of the patient first.
  • Mayo Clinic takes necessary precautions against inappropriate use or disclosure of protected health information.
  • Mayo Clinic employees are expected to access protected health information only as necessary to perform their jobs.
  • Mayo Clinic employees who violate these rules and policies are subject to sanctions, including discipline and termination.

The Health Care Providers Covered By This Notice

This notice covers Mayo Clinic and Mayo Clinic personnel, volunteers, students, and trainees. The notice also covers other health care providers that come to Mayo Clinic's facilities to care for patients (such as physicians, physician assistants, therapists, and other health care providers not employed by Mayo Clinic), unless these other health care providers give you their own notice of privacy practices that describes how they will protect your protected health information. Mayo Clinic may share your protected health information with these other health care providers for their treatment, payment and health care operations. This arrangement is only for sharing information and not for any other purpose.

A Word about Federal and State Law

Federal and state laws require Mayo Clinic to protect your medical information and federal law requires Mayo Clinic to describe to you how we handle that information. When federal and state privacy laws differ, and the state law is more protective of your information or provides you with greater access to your information, then state law will override federal law. For example, where we have specifically identified additional applicable state law requirements in this notice, the referenced Mayo entities will follow the more stringent state law requirements.

Part I — Most Common Uses and Disclosures

This section describes the most common circumstances in which Mayo Clinic may use or disclose protected health information.

Treatment

Mayo Clinic will use and disclose protected health information to provide, coordinate or manage your care. This includes communication and consultation between health care providers — doctors, nurses, technicians and other members of your medical team. This applies to disclosures for treatment purposes to health care providers both within and outside of Mayo Clinic. For example, following orthopedic surgery, your doctor may refer you for rehabilitation. Information will be shared between caregivers to ensure continuity of care.

Additional Applicable State Law Requirements

Minnesota Law generally requires patient consent for disclosures of protected health information by Mayo Clinic in Minnesota entities for treatment purposes, unless the disclosure is to a Mayo-related entity or consent is not possible due to a medical emergency.

Wisconsin Law requires your written consent to disclose information from your mental health records for treatment outside a treatment facility and in non-emergency situations.

Payment

Mayo Clinic will use and disclose protected health information to create bills and collect payment from insurance companies, Medicare and other payers. This may include providing information such as dates of service, symptoms, and diagnosis to your insurance company to show that Mayo Clinic provided medical services to you. Mayo Clinic also may disclose protected health information to another health care provider if such information is needed by the other health care provider to obtain payment for medical services provided to you.

Additional Applicable State Law Requirements

Minnesota law generally requires patient consent for disclosures of protected health information by Mayo Clinic in Minnesota entities for payment purposes, unless the disclosure is to a Mayo-related entity.

Florida Law generally requires patient consent for disclosures of protected health information by Mayo Clinic in Florida entities for payment purposes.

Iowa law permits Mayo Clinic to disclose protected health information for purposes of an independent review of a denial of a claim based on medical necessity.

Wisconsin law may require your written consent to disclose protected health information from your mental health treatment records or HIV test results for payment purposes. In the case of contracted behavioral health treatment, treatment records may be disclosed, without written authorization, to a state or county department as is necessary for, and only to be used for, billing or collection purposes.

Health care operations

Mayo Clinic will use and disclose protected health information if it is necessary to improve the quality of care we provide to patients or to run our health care facilities. These include activities to monitor and improve patient care, license staff to care for patients, prepare for state and federal regulatory reviews, train health care and non health care professionals, manage health care operations, and improve health care services. Here are some examples:

  • To reduce the infection rate after a surgery, it would be necessary to look at medical records to determine the rate of infections that occurred.
  • To be licensed to do a certain procedure, a doctor may be required to show that he or she has successfully completed a number of procedures under the supervision of another physician.
  • A Federal Drug Administration inspector may review patient records in a laboratory to ensure that accurate and complete records are maintained for patient safety.

Mayo facilities across the country, including but not limited to Mayo Clinic in Rochester, Mayo Clinic in Florida and Mayo Clinic in Arizona, and the Mayo Clinic Health System clinics and hospitals in Georgia, Iowa, Minnesota and Wisconsin, also work closely together to improve health care operations across the Mayo Clinic system, and we may use protected health information for those activities.

Mayo Clinic may also disclose protected health information to another health care provider who has treated you, or to your insurance company, if such information is needed for certain health care operations of the health care provider or insurance company, such as quality improvement activities, evaluations of health care professionals, and state and federal regulatory reviews.

Additional Applicable State Law Requirements

Minnesota law generally requires patient consent for disclosures of protected health information by Mayo Clinic in Minnesota Entities for health care operations purposes, unless the disclosure is to a Mayo- related entity.

Florida law generally requires patient consent for disclosures of protected health information by Mayo Clinic in Florida Entities for health care operations purposes.

Wisconsin law may require your written consent to disclose protected health information from your mental health treatment records or HIV test results for certain health care operations.

Patient contacts

At times, Mayo Clinic may access information, such as your name, address and general medical condition to contact you to:

  • set up or remind you about future appointments; provide information about treatment alternatives or other information that may be of interest to you; or
  • disclose health-related benefits or services that may be of interest to you.

Additional Applicable State Law Requirements

Florida law generally requires patient consent for Mayo Clinic in Florida entities to contact their patients for purposes of providing information regarding treatment alternatives, services, or goods.

Philanthropy

Mayo Clinic may contact you to raise funds to sustain the Mayo mission. For example, you may receive letters or other publications asking you to consider making a tax deductible contribution to Mayo. When conducting fundraising activities, Mayo Clinic may access only your basic demographic information (such as name and contact information), the dates that you were treated at Mayo Clinic, information about the department of service that provided treatment and the treating physician, information about your outcome, and your health insurance status. Mayo Clinic does not sell or rent patients' names or addresses to any organization outside of Mayo.

Facility Directory/Patient Census

Mayo Clinic may include your name, location in a facility, health condition (in general terms, such as "good," "fair") and religious affiliation (should you choose to provide one) in current patient lists for our facilities. This information is maintained for Mayo Clinic personnel to assist family members and other visitors or persons in locating you while you are in Mayo Clinic's facilities. For example, a relative may wish to visit you in the hospital and would need to know your hospital room number. A family member meeting you for an appointment may have forgotten which floor your appointment is on. This information is only shared with people who ask for you by name or with members of the clergy. If you indicate a religious affiliation, it will be shared only with members of the clergy. You can choose not to have such information released from the facility directory/patient census. If you do not want Mayo Clinic to release such information, please inform the person assisting you during registration and/or admission.

Additional Applicable State Law Requirements

Wisconsin law requires patient consent for disclosure of your health condition. Mayo Clinic in Wisconsin entities will not identify you in the Facility Directory as receiving, or having received, behavioral health treatment without your written authorization, and will not disclose such information to anyone without your written authorization, except as required or authorized by law.

Family Members and Others Involved in Your Care

Mayo Clinic may disclose relevant protected health information to a family member or friend who is involved with your care. We find that many patients want us to discuss their care with their family members and others to keep them up-to-date on your care, to help you understand your care, to help in handling your bills, or to help in the scheduling of your appointments. In a disaster situation, we also may disclose relevant protected health information to disaster relief organizations to help locate your family members or friends or to inform them of your location, condition or death. If family members or friends are present while care is being provided, Mayo Clinic will assume your companions may hear the discussion, unless you state otherwise. If you do not want Mayo Clinic to disclose your protected health information to your family members or others who are involved with your care or handling your bills, please inform the person assisting you during registration and/or admission. Mayo Clinic may also disclose your protected health information to a personal representative who has authority to make health care decisions on your behalf.

Additional Applicable State Law Requirements

Iowa law permits mental health professionals to disclose a limited amount of protected health information (including information about diagnosis, medication, and treatment plan) to your spouse, parent, adult child or adult sibling if you have a chronic mental illness. The disclosure will be made only if the family member is directly involved in your care and if the disclosure is necessary to assist the family member in caring for you. Unless you have been found incompetent, we will notify you of these disclosures.

Wisconsin law requires your written consent to share protected health information in most situations to family members or friends. With regard to information from your mental health treatment records, except for alcohol or drug dependence treatment information, Mayo Clinic may release a prognosis and diagnosis summary, medication list, and treatment plan description under certain circumstances and with certain limitations, to a spouse, domestic partner, parent, adult child or sibling who is directly involved in your care or monitoring your care. Unless you have been adjudged incompetent, Mayo Clinic will notify you of these disclosures. Additionally, with respect to behavioral health treatment, except drug and alcohol treatment programs, Mayo Clinic Health System may provide a patient's attorney and guardian ad litem, as well as County Corporation Counsel, your protected health information to prepare for matters related to detention, admission or commitment; release protected health information that would assist apprehension of a patient who has left the behavioral health unit without permission (where such permission is required). You have the right to request a restriction on the above notifications.

Medical Research

Medical research is vital to the advancement of medical science. Federal regulations permit use of protected health information in medical research, either with your authorization, when your name and most other identifiers have been removed and the recipient of the information signs a data use agreement, or when the research study at Mayo Clinic is reviewed and approved by an Institutional Review Board before any medical research study begins. In some situations, limited information may be used before approval of the research study to allow a researcher to determine whether enough patients exist to make a study scientifically valid.

Additional Applicable State Law Requirements

Minnesota law generally requires patient consent for disclosures of protected health information by Mayo Clinic in Minnesota Entities to outside researchers for medical research purposes. Mayo Clinic in Minnesota Entities will obtain such consent from their patients or refusal to participate in any research study, or will make a good faith effort to obtain such consent or refusal, before releasing any identifiable information to an outside researcher for research purposes.

Wisconsin law generally requires a written consent before we may disclose protected health information for research purposes to a researcher who is not affiliated with Mayo Clinic. In some situations, Mayo Clinic may disclose protected health information for research purposes to a researcher who agrees to protect the privacy of your information. Private pay patients may be able to opt out of the use or disclosure of your information for research purposes.

Florida law generally requires patient consent for disclosures of identifiable health information by Mayo Clinic in Florida entities to outside researchers for medical research purposes.

Georgia law generally requires patient consent for disclosures of protected health information to outside researchers for medical research purposes.

Part II Other Potential Uses and Disclosures

This section describes the less common circumstances in which Mayo Clinic may use or disclose protected health information.

To Avert a Serious Threat of Harm

Mayo Clinic may use and disclose protected health information to alert those able to prevent or lessen a serious and immediate threat to the health or safety of a patient, another person or the public.

Organ and Tissue Donation

If Mayo Clinic professionals determine that a patient might be a candidate for organ or tissue donation, Mayo Clinic may release protected health information to organizations that handle organ procurement, or organ, eye, tissue donation banks, or other health care organizations as needed to make organ or tissue donation and transplantation possible.

Additional Applicable State Law Requirements

Wisconsin law requires written consent to disclose behavioral health treatment records for organ or tissue donation purposes. Wisconsin law allows disclosures of HIV test results to a health care provider for the purpose of assuring medical acceptability of a donated organ.

Military Personnel

If a patient is a member of the United States Armed Forces, Mayo Clinic may release protected health information as required by military authorities. Mayo Clinic also may release protected health information about foreign military personnel to the appropriate foreign military authority. When the military organization is sponsoring the medical evaluation, the patient's protected health information is shared with both the patient and the sponsoring organization. Patients being evaluated on behalf of the military should be aware of these arrangements.

Additional Applicable State Law Requirements

Minnesota law generally requires patient consent for disclosures of protected health information by Mayo Clinic in Minnesota Entities for the military purposes referenced above, unless the disclosure is specifically required by federal law.

Wisconsin law permits the release of records pursuant to a written request from a government agency. Private pay patients may be able to opt out of this type of disclosure, unless the disclosure is required by law. Wisconsin law generally requires your written consent to disclose information from your mental health treatment records or HIV test results, unless the disclosure is otherwise authorized or required by law.

Workers' Compensation

Mayo Clinic may disclose protected health information for workers' compensation or similar programs as authorized or required by law. These programs provide benefits for work-related injuries or illness.

Additional Applicable State Law Requirements

Iowa law allows release of all information concerning an employee's physical or mental condition relative to the claim to any party making or defending a claim for benefits.

Wisconsin law permits disclosure of your protected health that is reasonably related to the condition for which you are claiming compensation when you report an injury alleged to be work-related.

Public Health Purposes

Mayo Clinic may disclose protected health information for public health purposes. The following are some examples of releases that are allowed for public health purposes:

  • to report vital statistics (e.g., births, deaths);
  • to report to the federal government adverse reactions to medication or safety problems with FDA-regulated products;
  • to notify people of product recalls; and to report communicable diseases to local, county, state, and federal health officials.

Additional Applicable State Law Requirements

Wisconsin law permits the release of records pursuant to a written request from a government agency. Private pay patients may be able to opt out of this type of disclosure, unless the disclosure is required by law. Wisconsin law generally requires your written consent to disclose information from your mental health treatment records, unless the disclosure is required by law. Wisconsin law generally requires your written consent to disclose information from your HIV test results, except under limited circumstances when the disclosure is required or permitted by state law.

Health Oversight Activities

Mayo Clinic may disclose protected health information to health oversight agencies that oversee our operations or personnel. For example, Mayo Clinic may need to disclose protected health information to the state agencies that oversee our health care facilities or licensed health care personnel (e.g., Department of Health, Medical Board, Nursing Board), or the federal agencies that oversee Medicare. These agencies need such information to monitor our compliance with state and federal laws.

Additional Applicable State Law Requirements

Wisconsin law permits the release of protected health information pursuant to a written request from a government agency. Private pay patients may be able to opt out of this type of disclosure unless the disclosure is required by law. Wisconsin law generally requires your written consent to disclose information from your mental health treatment records, unless the disclosure is required by law.

Lawsuits and Other Judicial Proceedings

Mayo Clinic may disclose protected health information in response to a valid court or administrative order. Mayo Clinic also may disclose protected health information in response to certain types of subpoenas, discovery requests or other lawful process.

Additional Applicable State Law Requirements

Iowa law permits the disclosure of information in the context of civil litigation where you have put your condition at issue in the litigation.

Law Enforcement Activities

Mayo Clinic may disclose protected health information to law enforcement officials. For example, we may release protected health information to law enforcement officials:

  • in response to a valid court order, grand jury subpoena, or search warrant;
  • to identify a suspect, fugitive or missing person;
  • about the victim of a crime under certain limited circumstances;
  • about a death believed to be a result of criminal conduct; or
  • about a crime committed on Mayo Clinic premises.

Additional Applicable State Law Requirements

Minnesota law generally requires patient consent for disclosures of protected health information by Mayo Clinic in Minnesota Entities for law enforcement purposes, unless the disclosure is in response to a valid court order or warrant.

Iowa law does not allow the disclosure of information regarding substance abuse to any law enforcement officer or law enforcement agency unless you have authorized the disclosure. We may disclose information relevant to a determination of whether a person is or continues to be a sexually violent predator to law enforcement agencies or the attorney general. In addition, we must report certain types of wounds, such as gunshot or stab wounds.

Wisconsin law permits disclosures in response to a valid court order from a court of record or subpoena signed by a judge, except for HIV test results which may be disclosed only pursuant to a court order. Wisconsin law generally does not allow disclosure of protected health information without a valid court order or subpoena signed by a judge. HIV test results may be disclosed only pursuant to a court order. Wisconsin law permits the disclosure of information pursuant to a written request from a government agency. Private pay patients may be able to opt out of this type of disclosure, unless the disclosure is required by law. Wisconsin law allows disclosures of information under limited circumstances when necessary to protect the patient or community from imminent and substantial danger. Wisconsin law allows the disclosure of certain information that is not a part of the health record to law enforcement. Mental health treatment records may be disclosed for certain limited identification or location purposes. Health professionals must report certain types of wounds, such as gunshots and burns (mental health treatment records and HIV test results may not be included in such reports). Wisconsin law permits the disclosure of information in connection with certain investigations of patient deaths.

Coroners, Medical Examiners and Funeral Directors

Mayo Clinic may release protected health information to a coroner or medical examiner when necessary to identify the deceased, determine the cause of death or as otherwise authorized by law. Mayo Clinic also may release protected health information to a funeral director as necessary to carry out the funeral director's duties, including arrangements after death.

Additional Applicable State Law Requirements

Minnesota law generally requires the consent of a patient's authorized family or legal representative for disclosures of protected health information by Mayo Clinic in Minnesota entities to funeral directors.

Wisconsin law generally requires written authorization to release protected health information to funeral directors. HIV test results and certain other protected health information may be disclosed to a funeral director when necessary to permit the funeral director to carry out his/ her duties. Wisconsin law requires written permission or a court order to release mental health treatment records to a coroner or medical examiner.

National Security Activities

Mayo Clinic may release protected health information to authorized federal officials for intelligence, counterintelligence or other national security activities authorized by law. Mayo Clinic also may disclose protected health information to authorized federal officials so they may provide protection to the President or other authorized individuals.

Additional Applicable State Law Requirements

Minnesota law generally requires patient consent for disclosures of protected health information by Mayo Clinic in Minnesota entities for national security purposes, unless the disclosure is specifically required by federal law.

Florida law generally requires patient consent for disclosures of protected health information by Mayo Clinic in Florida entities for national security purposes, unless the disclosure is specifically required by federal law.

Wisconsin law permits the release of records pursuant to a written request from a government agency. Private pay patients may be able to opt out of this type of disclosure, unless the disclosure is required by law.

Required by Law

Mayo Clinic will use or disclose protected health information when required by federal, state, or local laws. For example, Mayo Clinic is required to report certain gunshot wounds and other injuries that may have resulted from an unlawful act, and abuse or neglect of a child or vulnerable adult.

Permitted by Law

Mayo Clinic may use or disclose protected health information when permitted by federal, state, or local laws. For example, some Mayo Clinic entities are permitted to make a report to the Department of Transportation regarding a patient's ability to drive when the report is necessary to prevent or lessen a threat to the health or safety of a person or the public.

Uses and Disclosures Pursuant to an Authorization

Except as described in this notice or specifically required or permitted by law, Mayo Clinic will not use or disclose your protected health information without your specific written authorization. At times, a Mayo Clinic entity may ask you to provide specific written permission to allow the Mayo Clinic entity to use or disclose protected health information about you. Mayo Clinic generally will not use or disclose your protected health information for marketing purposes, in exchange for remuneration, or use or disclose any psychotherapy notes about you unless Mayo Clinic receives your authorization to do so. A valid authorization may be revoked in writing at any time. Written revocation of authorization must be submitted to the applicable Mayo Clinic entity and addressed to the Health Information Management Services. Once the authorization is revoked, the Mayo Clinic entity will no longer be allowed to use or disclose protected health information for the purposes described in the authorization except to the extent the Mayo Clinic entity has already taken action based upon the authorization.

Information with Additional Protections

Certain types of protected health information may have additional protection under federal or state law. For example, protected health information about mental health, HIV/AIDS and genetic testing results is treated differently than other types of protected health information under certain state laws. Additionally, federally assisted alcohol and drug abuse programs are subject to certain special restrictions on the use and disclosure of alcohol and drug abuse treatment information. To the extent applicable, Mayo Clinic would need to get your written permission before disclosing that information to others in many circumstances.

Part III Patients' Rights with Respect to Protected Health Information

This section describes the rights of Mayo Clinic patients to protected health information.

Right to Inspect and Copy

You have the right to inspect and to request a copy of information maintained in Mayo Clinic's designated medical record about you. This includes medical and billing records maintained and used by Mayo Clinic to make decisions about your care.

To obtain or inspect a copy of your protected health information, submit a written request to the applicable Mayo Clinic entity and address the request to the attention of the Health Information Management Services. Mayo Clinic generally may charge a reasonable, cost-based fee to cover the expense of providing copies. Mayo Arizona Entities are not permitted under Arizona law to charge a fee if the information is needed for treatment purposes.

Most patients have full access to inspect and receive a copy of the full medical record. On rare occasions, Mayo Clinic may deny a request to inspect and receive a copy of some information in the medical record. For example, this may occur if, in the professional judgment of a patient's physician, the release of the information would be reasonably likely to endanger the life or physical safety of the patient or another person.

Additional Applicable State Law Requirements

Wisconsin law permits most patients to have full access to inspect and receive a copy of the full medical record. On rare occasions, Mayo Clinic may deny a request to inspect and receive a copy of some information in the medical record when, in the professional judgment of a physician, denial of access is necessary to prevent an imminent and substantial danger to the patient or others.

Right to Request Alternate Methods of Communication

You have a right to request that Mayo Clinic communicate with you in certain ways (such as a letter or by phone) or at a certain location. For example, you may ask that we contact you only at home or only at your place of business. In this situation, you may submit a written request to the applicable Mayo Clinic entity specifying the communication method or alternative location being requested. The request should be addressed to the attention of the Site Privacy Officer. Mayo Clinic will accommodate reasonable requests. However, if the request could result in Mayo Clinic not being able to collect for services or cause significant administrative burden, Mayo Clinic reserves the right to require you to provide additional information about how payment for services will be handled.

Right to Request Amendment

You have the right to request that your protected health information in Mayo Clinic's designated medical record for you be amended. If you wish to request amendment of the information in your record, submit a written request to the applicable Mayo Clinic entity and address the request to the attention of the Health Information Management Services. The request must include a reason to support the amendment. Mayo Clinic may deny a request for amendment based upon any of the following circumstances:

  • the request is not in writing or does not include a supporting reason;
  • the information you want to change was not created by Mayo Clinic, and the originator of the information is available to make the amendment;
  • the information is not part of the designated medical record; or
  • the information in the record is accurate and complete.

If Mayo Clinic denies your request for an amendment, Mayo Clinic will give you a written explanation of the denial. If you still disagree with the explanation provided, you can submit your written disagreement to Mayo Clinic as referenced above, or you can ask that your request for amendment and explanation of the denial, or an accurate summary of such information, be included in any future disclosure of the pertinent protected health information. If you submit a statement of disagreement, Mayo Clinic may include a rebuttal statement addressing your statement of disagreement in the designated medical record.

Right to a List of Certain Disclosures

You can ask Mayo Clinic for a list of the persons or organizations to which Mayo Clinic has disclosed your protected health information. This list would provide you with a summary of certain disclosures Mayo Clinic has made that you would not otherwise be in a position to know about. The following are examples of disclosures that would not be included in the list:

  • disclosures to carry out treatment, payment and health care operations;
  • disclosures made directly to you (the patient) or disclosures that you have specifically authorized;
  • disclosures made from the facility directory/patient census;
  • disclosures to persons involved in your care;
  • disclosures incident to a use or disclosure that is otherwise permitted or required by law;
  • disclosures made for national security or intelligence purposes;
  • disclosures made to correctional institutions or law enforcement officials having custody over a patient; or
  • disclosures that took place before April 14, 2003.

To obtain a copy of the list, submit a written request to the applicable Mayo Clinic entity and address the request to the attention of the Site Privacy Officer. Your request must state a time period (beginning no earlier than April 14, 2003 when the federal privacy rules go into effect and for no longer than six years). The first list requested within a 12-month period shall be provided at no charge. For additional lists requested during the same 12-month period, Mayo Clinic may charge for the costs of providing the list.

Right to Request Restrictions

You can ask Mayo Clinic to restrict the use or disclosure of protected health information about you for treatment, payment, or health care operations. If you or someone on your behalf pays for a health care item or service in full, you can request that Mayo Clinic not disclose information about the item or service to your health plan for payment or health care operations purposes, and Mayo Clinic will agree to your request unless required by law to make the disclosure. Your request must be in writing and submitted to the applicable Mayo Clinic entity. The request should also be addressed to the attention of the Site Privacy Officer. Mayo Clinic will carefully consider all requests. However, because of the integrated nature of Mayo Clinic's medical record, Mayo Clinic is not generally able to honor most requests, nor is Mayo Clinic legally required to do so.

Right to Notice of Privacy Practices

You have the right to obtain a paper copy of this notice upon request, even if you have agreed to receive the notice electronically. To obtain a paper copy of this notice, submit a written request to the any Mayo Clinic entity. The request should be addressed to the attention of the Site Privacy Officer.

Complaints

If you want to file a complaint or express concerns about Mayo Clinic's use or disclosure of Protected Health Information, please contact the applicable Mayo Clinic entity as follows:

Mayo Clinic in Minnesota, Iowa, and Wisconsin Entities:
Mayo Clinic in Rochester
Attn: Office of Patient Affairs
200 First Street S.W.
Rochester, Minnesota 55905
Phone: 507-284-4988

Mayo Clinic in Florida and Georgia Entities:
Mayo Clinic in Jacksonville
Attn: Privacy Officer
4500 San Pablo Road
Jacksonville, Florida 32224
Phone: 904-953-2930

Mayo Clinic in Arizona Entities:
Mayo Clinic in Arizona
Attn: Patient Administrative Liaison Office
13400 East Shea Boulevard
Scottsdale, Arizona 85259
Phone: 480-301-4938

You also may file a written complaint with the United States Department of Health and Human Services — Office for Civil Rights. Mayo Clinic honors your right to express concerns regarding your privacy. Mayo Clinic would not — nor could it legally or ethically — take action against you for filing a concern or complaint regarding the use, disclosure, and rights of your protected health information.

Key Information about this Notice

  • This is a revised notice for the Mayo entities and health care practice sites referenced on the first page (collectively referred to as "Mayo Clinic"). The effective date of this revised notice is September 23, 2013.
  • From time to time, Mayo Clinic may change its practices concerning how we use or disclose protected health information, or how we will implement patient rights concerning their information. Mayo Clinic reserves the right to change the terms of this notice and make the new notice provisions effective for all protected health information maintained by Mayo Clinic. Mayo Clinic will follow the terms and conditions of the notice that is currently in effect.
  • When the notice is revised, it will be posted at Mayo Clinic facilities. It will also be available upon request at Mayo Clinic facilities, by mail, and on the Mayo Clinic's website at http://www.mayoclinic.org/.

Need More Information?

If you have any questions, or would like to discuss this notice in more detail, please contact the privacy officer for the applicable Mayo Clinic entity.

Mayo Clinic in Minnesota Entities:
Privacy Officer — 507-266-6286
http://www.mayoclinic.org/

Mayo Clinic in Florida Entities:
Privacy Officer — 904-953-2930
http://www.mayoclinic.org/jacksonville/

Mayo Clinic in Arizona Entities:
Privacy Officer — 480-301-6784
http://www.mayoclinic.org/scottsdale/

Mayo Clinic Health System Entities:
http://www.mayoclinichealthsystem.org/
Privacy Officers by location:

Southeast Minnesota Region — 507-377-6272

  • Includes Albert Lea, Alden, Farmington, Kiester, MN, Lake Mills, Charles City, IA, New Richland, Wells, Austin, Adams, LeRoy, Cannon Falls, Lakeville, Faribault, MN, Red Wing, Zumbrota, Kenyon, Blooming Prairie, MN, Ellsworth, WI, Wabasha, Elko New Market, Northfield, Owatonna, Lake City, Plainview, Lonsdale, MN, Alma, WI

Southwest Minnesota Region — 507-385-6395

  • Includes Armstrong, IA, Fairmont, Blue Earth, Sherburn, Montgomery, Truman, Waseca, Mankato, Janesville, Lake Crystal, Lamberton, Belle Plaine, New Prague, Springfield, St. James, St. Peter, Trimont, Waterville, Le Sueur, MN

Northwest Wisconsin Region — 715-838-3646

  • Includes Eau Claire, Chippewa Falls, Osseo, Mondovi, Barron, Cameron, Chetek, Prairie Farm, Bloomer, Colfax, Rice Lake, Menomonie, Elmwood, Glenwood City, WI, Northwest Health Ventures, Inc., d/b/a Midelfort Pharmacy & Home Medical, Northwest Wisconsin HomeCare, Inc., Northwest Wisconsin Supportive HomeCare, Inc., WI

Southwest Wisconsin Region — 608-392-3968

  • Includes La Crosse, Onalaska, WI, Arcadia, WI, Caledonia, MN, Decorah, IA, Holmen, WI, La Crescent, Mabel, MN, Sparta, WI, Tomah, WI, Waukon, IA, Prairie du Chien, WI

Georgia — 904-953-2930

  • Includes Waycross, GA

Applies to Mayo Clinic locations in Arizona, Florida, Rochester and Mayo Clinic Health System.

Jan. 14, 2013