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*DHS-4127-ENG* DHS-4127-ENG 10-17 Division of Licensing/Office of Inspector General NOTICE OF PRIVACY PRACTICES This notice describes how medical information and other private information about you may be used and disclosed and how you can get access to this information. Review it carefully. This information is available in other forms to people with disabilities by contacting us at (651) 431-6500 (voice). TTY/TDD users can call the Minnesota Relay at 711 or (800) 627-3529. For the Speech-to-Speech Relay, call (877) 627-3848. You have privacy rights under the Minnesota Government Data Practices Act and the federal Health Insurance Portability and Accountability Act (HIPAA). These laws protect your privacy, but also let us give information about you to others if a law requires it. We may tell you before we give the information. Why are we asking you for this information? We have received a report of possible maltreatment and/ or licensing violations occurring in a program licensed by the Minnesota Department of Human Services (DHS) or Minnesota Department of Corrections (DOC). Do you have to answer the questions we ask? Generally the law does not say you have to give us this information. You have the right to refuse to answer our questions. How will we use the information that you give us? The information you supply us with will assist us in determining: whether maltreatment has occurred and, if maltreatment has occurred, whether an individual or the facility is responsible; and/or whether any violations of Minnesota rules and/or statutes have occurred. The information you supply may also be used to make reports, do research, do audits and evaluate our programs. What will happen if you don’t answer the questions we ask? If you refuse to answer our questions, we must conduct our investigation and make our determination without the information you may be able to provide. If you knowingly withhold relevant information, or give false or misleading information in connection with an investigation, it may result in a licensing action. Who will get a copy of this information and with whom will we share this information? During an investigation: All information that we collect is confidential until the investigation is completed. Confidential means that we cannot share the information with anyone other than authorized government agencies, such as county adult or child protection workers, the Health Department, the Department of Corrections, the Ombudsman’s Office or a law enforcement agency if one of those agencies is also investigating this report. Confidential also means that the subject of the information has no right to see the information. When the investigation is completed: Some information becomes public, some becomes private data about individuals and some remains confidential. • Your name or the name of a license holder, or both will be public if: • A court issues an order making it public or if the information becomes a part of a judicial or administrative proceeding; or • You are a license holder or you work for, live with, or are otherwise affiliated with a license holder, and as a result of an investigation you are determined to be responsible for maltreatment, if: - A licensing action has been taken against the license holder based upon your maltreatment determination; and - The license holder provides any of these services: family child care, child care center, foster care in a provider’s own home, adult foster care or adult day care in the provider’s own home. • If you are a reporter of an incident we are investigating, your identity as the reporter will remain confidential. Public means that anyone can have access to the information. Private means that the person whom the information is about may access the information or may give permission for others to access the information. Confidential information is not accessible to the subject of the information, but is accessible to individuals or agencies that need it to do their job. We may give information about you to anyone else authorized under the state or federal law. ---PAGE BREAK--- What will happen when the investigation is completed? When the investigation is completed a public summary will be prepared that contains some of the factual information obtained during the investigation. The public summary will be written in a way that keeps the identity of anyone who gave us the information private. Some readers of the public summary may believe that they recognize the persons referred to in the public summary. Without your permission, our office will not confirm or deny your identity to anyone, other than you or authorized governmental agencies. If licensing violations and/or maltreatment occurred, DHS or DOC will determine if a licensing action will be ordered. If an individual is found responsible for serious and/or recurring maltreatment s/he may be disqualified from a direct contact position. At the time of the investigation an individual will be advised of any rights to challenge these determinations. You have the right to information we have about you. • You may ask if we have information about you and get copies. You may have to pay for copies. • You may give other people permission to see and have copies of private information about you. • If we have collected health information about you, we may use it only for purposes that we have listed in this notice. • You have the right to ask us to share health information with you in a certain way or in a certain place. If we find that your request is reasonable, we will grant it. • You can ask us to restrict uses or disclosures of your health information. We are not required to agree to your restrictions. • You have the right to receive a record of the people or organizations that we have shared your health information with. If you want a copy of this record, you must send a request in writing to our privacy official. • If you do not understand the information, you may ask to have it explained to you. What privacy rights do children have? If you are under 18, parents may see information about you and allow others to see this information, unless you have asked that this information not be shared with your parents or it involved medical treatment for which parental consent is not required. You must make this request in writing and say what information you want withheld and why. If the agency agrees that sharing the information is not in your best interest, the information will not be shared with your parents. If the agency does not agree, the information will be shared with your parents if they ask for it. When parental consent for medical treatment is not required, information will not be shown to parents unless the health care provider believes that failing to share this information would jeopardize your health. What if you believe your privacy rights have been violated? You may complain if your privacy rights have been violated. You cannot be denied service or treated badly because you have made a complaint. If you believe that your medical privacy was violated by your doctor or clinic, a health insurer, a health plan, or a pharmacy, you may send a written complaint either: • Directly to that organization, or • To the federal Office of Civil Rights at: U.S. Department of Health and Human Services Office of Civil Rights, Region V 233 N. Michigan Ave., Suite 240 Chicago, IL 60601 (312) 886-2359 (Voice) or Toll free (800) 368-1019/(866) 282-0659 (312) 353-5693 (TTY/TDD) (312) 886-1807 (Fax) If you think that the Minnesota Department of Human Services has violated your privacy rights you may send a written complaint to the U.S. Department of Health and Human Services at the address above, or to: Minnesota Department of Human Services Privacy Official PO Box 64998 St. Paul, MN 55164-0998 Sign below to indicate that you have received this privacy notice. RECIPIENT OF NOTICE OR LEGALLY AUTHORIZED REPRESENTATIVE DATE