Health Information Privacy Notice
Summit Fiscal Agency, Inc.
Effective April 14, 2003

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

This Notice of Privacy Practices describes how Summit Fiscal Agency, Inc. may use and disclose your protected health information to provide services and treatments, to obtain payment for those services and treatments, to carry out health care operations, to interact with program officials at the state or county, and for other purposes that are permitted or required by law. It also describes your rights to review and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present, or future physical or mental health or condition and related health care services.

We are required by law to maintain the privacy of protected health information, to provide you with a Notice of Privacy Practices, and to abide by the terms of this Notice. We may change the terms of our Notice at any time. The new Notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with a copy of the current Notice of Privacy Practices, by calling the Summit Fiscal Agency, Inc. office at 952-544-2787 and requesting that a current copy of this Notice be sent to you in the mail, or by asking for one at the time of your next contact with Summit Fiscal Agency, Inc. staff.

Summit Fiscal Agency, Inc. will disclose your protected health information to outside parties only as described in this Notice. Your protected health information may be used by Summit Fiscal Agency, Inc., and disclosed by Summit Fiscal Agency, Inc. to others outside our organization that are involved in providing or administering services to you, as described in this Notice. Summit Fiscal Agency, Inc. will limit use and disclosure of protected health information to the minimum amount necessary.

This Notice may be given to program consumers who receive services through Summit Fiscal Agency, Inc. programs. If the client is unable to understand this Notice, it may be given to the individual or individuals designated as legal representatives for consumers, who have responsibility for making decisions on behalf of consumers. You, or the person making decisions on your behalf, will be asked by Summit Fiscal Agency, Inc. to sign this Notice of Privacy Practices. Your signature indicates that you acknowledge that you have received a copy of this Notice.

Uses of Protected Health Information by Summit Fiscal Agency, Inc.
Following are examples of the types of uses of your protected health care information that Summit Fiscal Agency, Inc. is permitted to make. These examples are not meant to be exhaustive or all-inclusive, but to describe the types of uses that may be made by Summit Fiscal Agency, Inc.

Providing Services and Treatment: We will use and disclose your protected health information to provide, coordinate, or manage the services we provide to you. This includes the coordination or management of your services with a third party, such as contractors or consultants with whom Summit Fiscal Agency, Inc. contracts to provide administrative services, and to vendors from whom you have purchased services and are seeking payment. We will also disclose protected health information to other health service providers with whom you work. For example, your protected health information may be provided to a Summit Fiscal Agency, Inc. member agency that is providing services to you.

Payment: Your protected health information will be used, as needed, to obtain payment for your services. This may include disclosures to county, state, or private payers, depending on the type of program, who may need information to determine eligibility or coverage, to determine insurance benefits, to review services provided to you, and to undertake utilization review activities. For example, obtaining approval for expenditures may require that your protected health information be disclosed to the county caseworker or a billing department.

Healthcare Operations: We may use or disclose your protected health information in order to support the business activities of Summit Fiscal Agency, Inc. These activities include, but are not limited to, quality assessment activities, employee review activities, training, licensing, and communications with you or employees that work with you about existing or new products or services offered by or through Summit Fiscal Agency, Inc., and conducting or arranging for other business activities.

For example, we may disclose your protected health information to evaluators, accountants, and government officials who work with Summit Fiscal Agency, Inc. to administer a program. In addition, we may use a sign-in sheet at a meeting where you will be asked to sign your name. We may use or disclose your protected health information, as necessary, to contact you.

We may share your protected health information with third party “business associates” that perform various activities (such as billing and accounting services, evaluation, etc.) for Summit Fiscal Agency, Inc. Whenever an arrangement between Summit Fiscal Agency, Inc. and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.

We may use or disclose your protected health information, as necessary, to provide you with information about service alternatives or other related benefits and services that may be of interest to you. For example, your name and address may be used to send you a newsletter about Summit Fiscal Agency, Inc. and the services we offer. We may also send you information about our products or services that we believe may be beneficial to you or those employees you work with. You may contact our Privacy Officer to request that these materials not be sent to you. We may use or disclose your demographic information in order to contact you for Summit Fiscal Agency, Inc. fundraising activities. If you do not want to receive these materials, please contact our Privacy Officer and request that these fundraising materials not be sent to you.
Uses and Disclosures of Protected Health Information Based upon Your Written Authorization

Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke your written authorization, at any time, in writing, except to the extent that Summit Fiscal Agency, Inc. has taken an action in reliance on the use or disclosure indicated in the authorization. We will obtain your written authorization before disclosure of protected health information for such activities as marketing, research not approved by an Institutional Review Board, inquiries by employers or insurers, and other uses not permitted or required by law.

Other Permitted and Required Uses and Disclosures
We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. In this case, only the protected health information that is relevant to your health care will be disclosed.

Others Involved in Your Healthcare: Unless you object, we may disclose your protected health information to a member of your family, a relative, a close friend, or any other person you identify, if disclosure directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative, or any other person that is responsible for your care of your location, general condition or death.

Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.
Emergencies: We may use or disclose your protected health information in an emergency. If this happens, Summit Fiscal Agency, Inc. shall attempt to obtain your consent as soon as reasonably possible. If Summit Fiscal Agency, Inc. has attempted to obtain your consent but is unable to obtain your consent, Summit Fiscal Agency, Inc. may still use or disclose your protected health information to respond to the emergency.

Communication Barriers: We may use and disclose your protected health information if Summit Fiscal Agency, Inc. attempts to obtain consent from you but is unable to do so due to substantial communication barriers and Summit Fiscal Agency, Inc. determines, using professional judgment, that you intend to consent to use or disclosure under the circumstances.

Other Permitted and Required Uses and Disclosures That May Be Made Without Your Authorization or Opportunity to Object

We may use or disclose your protected health information in the following situations without your consent or authorization.

These situations include:
Required By Law: We may use or disclose your protected health information to the extent that the use or disclosure is authorized or required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law.

Public Health: We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury, or disability. We may also disclose your protected health information, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority.
Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

Health Oversight: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.

Abuse, Violence, or Neglect: We may disclose your protected health information to a public health or enforcement authority that is authorized by law to receive reports of abuse, violence, or neglect. In addition, we may disclose your protected health information to the governmental entity or agency authorized to receive such information if we believe that you have been a victim of abuse, neglect, or domestic violence. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.

Food and Drug Administration: We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, or track products; to enable product recalls; to make repairs or replacements, or to conduct post-marketing surveillance, as required.
Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request, or other lawful process.

Law Enforcement: We may disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes required by law, (2) limited information requests for identification and location purposes, (3) requests pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) occurrence of a crime or criminal investigation.

Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out his duties.
Research: We may disclose your protected health information to researchers when an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information has approved their research.

Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.

Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of benefit eligibility, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.

Workers’ Compensation: Your protected health information may be disclosed by us as authorized to comply with workers’ compensation laws and other similar legally-established programs.
Inmates: We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you.

Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et. seq.

Your Rights
You have the following rights with respect to your protected health information. Your requests to Summit Fiscal Agency, Inc. should be in writing.

You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you that is contained in a designated record set for as long as we maintain the protected health information. A “designated record set” contains medical and billing records and any other records that Summit Fiscal Agency, Inc. uses for making decisions about you. We may charge you a reasonable fee to provide copies to you. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and protected health information that is subject to law that prohibits access to protected health information. Depending on the circumstances, you may have a right to appeal a decision to deny access. Please contact our Privacy Officer if you have questions about access to your medical record.

You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment, or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.
Summit Fiscal Agency, Inc. is not required to agree to a restriction that you may request. If Summit Fiscal Agency, Inc. believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. If Summit Fiscal Agency, Inc. does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with Summit Fiscal Agency, Inc. You may request a restriction by contacting our Privacy Officer.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Officer.

You may have the right to have Summit Fiscal Agency, Inc. amend your protected health information. This means you may request an amendment of protected health information about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Officer to determine if you have questions about amending your medical record.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment, or healthcare operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you, to family members or friends involved in your care, or for notification purposes. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003, for a specific timeframe. The right to receive this information is subject to certain exceptions, restrictions, and limitations.

Complaints
If you need more information about this notice, our privacy policy, or your rights, contact the Summit Fiscal Agency, Inc. Privacy Officer. You may complain to us or to the United States Secretary of Health and Human Services if you believe your privacy rights have been violated by us.

You may file a complaint with us by notifying our Privacy Officer of your complaint. We will not retaliate against you for filing a complaint.

You may contact our Privacy Officer at:
Summit Fiscal Agency, Inc.
6009 Wayzata Boulevard, Suite 1A
Saint Louis Park, MN 55416
952-544-2787
952-544-2788 fax
952-224-4089 TTY
1-866-366-2787 toll free

This Notice was published and becomes effective April 14, 2003.