HIPAA Privacy Notice


Our care center is permitted by Federal and State privacy laws to use and disclose your health information directly or through a business associate to carry out Treatment, Payment, and Healthcare Operations (TPO). Protected Health Information (PHI) is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examination and test results, diagnoses, treatment and applying for future care or treatment. It also includes billing documents for those services. If we use a business associate, that person or entity will be required to appropriately safeguard your PHI.

Examples of uses of your health information for Treatment purposes are:

  • A nurse obtains treatment information about you and records it in a health record.
  • During the course of your treatment, the physician determines that a consult with another specialist is necessary. Your health information is shared with the specialist to obtain input for possible further treatment.

Example of use of your health information for Payment purposes:

  • We submit requests for payment to your insurance company. The health insurance company helping us to obtain payment requests some of your protected health information from us regarding medical care that you received. We will provide information to them about you and the care that was given.

Example of use of your information for Healthcare Operations:

  • We may obtain services from business associates such as: training programs, credentialing agencies, medical review teams, legal services, and billing services. We will share information about you with such business associates as necessary to obtain these services.


The health and billing records we maintain are the physical property of the company. You have the following rights with respect to your Protected Health Information:

  1. Right to obtain a paper copy of the Notice of Privacy Practices (NPP) for Protected Health Information (PHI) (“Notice”) by making a request at our care center to the following person: Krista Siddiqui.
  1. Right to give written authorization for use or disclosures of your PHI and the right to revoke an authorization;
  1. Right to request a restriction on certain uses and disclosures of your health information by delivering the request in writing to our care center. We are not required to grant the request, but we will comply with any request granted;
  1. Right to inspect and receive a copy your health record and/or billing record. You may request a copy of your electronic medical record in either a paper or an electronic form. You may exercise this right by delivering the request in writing to our care center contact person, Krista Siddiqui, using the form we will provide to you upon request. You have the right to, appeal a denial of access to your protected health information except in certain circumstances;
  1. Right to instruct our care center not to share information about your treatment with your health plan, if you paid out of pocket in full for the Healthcare item or services;
  1. Right to request that your healthcare record be amended to correct incomplete or incorrect information by delivering a written request to our agency contact person, Krista Siddiqui, using the form we will provide to you upon request. We are not required to make such amendments. You may file a statement of disagreement. The request for amendment and any denial will be attached in all future disclosures of your protected health information. If we agree to your request, we will note the amendment in future releases of that record and make reasonable efforts to inform persons who have already been given your records;
  1. Right to receive notification of any breach of your unsecured protected health information;
  1. Right to receive an accounting of certain disclosures for the previous six (6) years of your health information as required to be maintained by law by delivering a written request to our care center using the form we will provide to you upon request. An accounting will not include internal uses of information for treatment, payment or operations, disclosures made to you or made at your request or disclosures made to family members or friends in the course of providing care;
  1. Right to confidential communications. You may make a reasonable request that communication of your health information be made by alternative means or at an alternative location by delivering the request in writing to our care center, using the form we will give you upon request;
  1. Right to opt out of receiving fundraising communications, if the care center intends to contact you to raise funds for the care center.

If you want to exercise any of the above rights, please contact in person or in writing, during normal hours. Our contact person will provide you with the appropriate forms and assistance on the steps to take to exercise your rights.


Our care center is required to:

  1. Maintain the privacy and security of your health information as required by law;
  1. Provide you with a notice of our duties and privacy practices pertaining to the information we collect and maintain about you;
  1. Abide by the terms of our Notice of Privacy Practices;
  1. Notify you if we cannot accommodate a requested restriction or request;
  1. Accommodate your reasonable requests regarding methods to communicate health information with you; and Accommodate your request for an accounting of disclosures;
  1. Obtain your authorization before using or disclosing protected health information (PHI) for marketing and fundraising purposes, or a disclosure that constitute a sale of PHI, and or other uses and disclosures not described in this NPP, according to the HIPAA Privacy and Security laws. (Most uses and disclosures of psychotherapy notes will require an authorization.);
  1. Comply with the Title IV of the Civil Rights Act of 1964 by taking reasonable steps to ensure Limited English Proficient persons understand the content of the NPP.

We reserve the right to amend, change, or eliminate provisions in our privacy and access practices, and to enact new provisions and make the new provisions effective for all the PHI we maintain. If our information practices change, we will amend our Notice of Privacy Practices. You are entitled to receive a revised copy of the Notice of Privacy Practices by calling and requesting a copy or by visiting our care center, Zumbrota Health Services at 433 Mill Street, Zumbrota, MN 55992, and picking up a copy.


If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact:

Krista Siddiqui
433 Mill Street
Zumbrota, MN 55992
(507) 732-8132

Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our agency by requesting a complaint form and delivering the written complaint to Krista Siddiqui. You may also file a complaint by mailing it or e-mailing it to the Secretary of Health and Human Services (HHS) whose street address and e-mail address is:

Region V, Office for Civil Rights
U.S. Department of Health and Human Services
233 N. Michigan Ave., Suite 240
Chicago, IL 60601

E-Mail: OCRComplaint@hhs.gov.
Voice Phone: (312) 886 – 2359
FAX: (312) 886 – 1807
TDD: (312) 353 – 5693

  • We cannot, and will not require you to waive the right to file a complaint with the Secretary of HHS as a condition of receiving treatment from the care center.
  • We cannot, and will not, retaliate against you for filing a complaint either with us or with the Secretary of HHS.


Resident/Tenant/Consumer Contact:

We may contact you to provide you with appointment reminders, with information about treatment alternatives, or with information about other health-related benefits and services that may be of interest to you. We may also contact you as part of a fund raising effort.

Notification – Opportunity to Agree or Object:

Using our best judgment, we may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person’s involvement in your care or in payment for such care if you do not object or in an emergency.

Care Center Directories:

Unless you object, we will post and disclose in our care center directory, your name and the location of your room.

  • We may also use your name, your room number, and your religious affiliation to maintain a resident/tenant/consumer directory.
  • We may disclose your name and room number to visitors who ask for you by name and your religious affiliation for disclosures to members of the clergy.
  • We may use or disclose your PHI to assist in disaster relief efforts.

Opportunity to Agree or Object Not Required:

We may use or disclose your PHI without your authorization or without your opportunity to object in certain limited circumstances established by the HIPAA Privacy Rule with regard to Public Health activities including the following:

  • Controlling DiseaseAs required by law, we may disclose your PHI to Public Health or legal authorities.
  • Vulnerable Adult Abuse & NeglectWe may disclose PHI to public authorities as allowed or required by law to report incidents of abuse or neglect. Professional judgment will be exercised in disclosing PHI in the event that the disclosure of such information could prevent serious harm to the alleged abused individual or any other potential victims.
  • Food and Drug Administration (FDA)We may disclose to the FDA your PHI relating to adverse events such as food, supplements, products and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacements.
  • Oversight AgenciesFederal law allows us to release your PHI to appropriate health oversight agencies or for health oversight activities to include compliance surveys, complaint investigations, audits, civil, administrative, or criminal investigations: inspections, licensures, certification, or disciplinary actions; and for similar reasons related to the administration of healthcare.
  • Judicial/Administrative ProceedingsWe may disclose your PHI in the course of any judicial or administrative proceedings as allowed or required by law, or as directed by a proper order of an administrative or judicial official, provided that only the PHI released is what is expressly authorized by such order, or in response to a subpoena, discovery request or other lawful process.
  • Law EnforcementWe may disclose your PHI for law enforcement purposes as required by law and certain other law enforcement purposes where allowed by law, such as when required by court order, including laws that require reporting of certain types of wounds or other physical injury.
  • Coroners, Medical Examiners, and Funeral DirectorsWe may disclose your PHI to funeral directors or coroners consistent with applicable law to allow them to carry out their duties.
  • Organ Procurement OrganizationsConsistent with applicable law, we may disclose your PHI to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs, eyes, or tissue for the purpose of donation and transplant.
  • ResearchWe may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your PHI.
  • Threat to Health and SafetyTo avert a serious threat to health or safety, and standards of ethical conduct, we may disclose your PHI consistent with applicable law to prevent or lessen a serious, imminent threat to the health or safety of a person or the public.
  • For Specialized Governmental FunctionsWe may disclose your PHI for specialized government functions as authorized by law such as to Armed Forces personnel, for national security purposes, or to public assistance program personnel.
  • Correctional Institutions – If you are an inmate of a correctional institution, we may disclose to the institution or its agents the PHI necessary for your health and the health and safety of other individuals.
  • Workers CompensationIf you are seeking compensation through Workers Compensation, we may disclose your PHI to the extent necessary to comply with laws relating to Workers Compensation.
  • Minnesota Specific ReferenceAttached to this Privacy Notice is a Minnesota specific reference called “Access to Health Records Notice of Rights”, which includes disclosures that are required or allowed by Minnesota law, including, but not limited to the disclosures described on the attachment.

Other uses and disclosures besides those identified in this Notice will be made only as otherwise authorized by law or with your written authorization which may be revoked except to the extent information has previously been used or disclosed or action has already been taken in reliance on the authorization.

We maintain a website that provides information about our care center. This Notice will be posted on the website and will be available electronically through the web site at www.sfhs.org.

If we request to provide this Notice to you by e-mail and you agree (for as long as this agreement has not been withdrawn), we may provide this Notice to you in that manner. You will still have the right to request a paper copy of this Notice.