Privacy Policy

Northern Health Centers, Inc. will provide an individual with a notice written in plain language of the uses and disclosures of protected health information that may be made by Northern Health Centers, Inc. and of the individual's rights and Nothern Health Centers, Inc.'s legal duties with respect to protected health information. [45 CFR 164.520 (a)(1)]

Northern Health Centers, Inc. will maintain the privacy of protected health information, will abide by the terms of the notice currently in effect and will provide the individual with any applicable revisions to the notice. [45 CFR 164.520 (b)(1)(v)(A-C)]

Notice Procedure
Northern Health Centers, Inc. will develop and implement a notice of privacy practices written in plain language and containing the elements required by the federal privacy rule. [45 CFR 164.520(b)(1)] Refer to Notice of Privacy Practices form which will be referenced as “Notice” throughout this procedure.

Note: The federal privacy rule does not require Northern Health Centers, Inc. to provide the notice to an inmate. [45 CFR

Process for Providing Notice
Northern Health Centers, Inc. will make the Notice available on request to any person and to individuals as required by the federal privacy rule. [45 CFR 164.520(c) Refer to Notice of Privacy Practices form.

If Northern Health Centers, Inc. maintains a web site that provides information about their customer services or benefits, Northern Health Centers, Inc. will prominently post its Notice on the web site and make the Notice available electronically through the web site. [45 CFR 164.520(c)(3)(i)]

Northern Health Centers, Inc. may provide the Notice to an individual by e-mail, if the individual agrees to electronic Notice and the agreement has not been withdrawn. If Northern Health Centers, Inc. knows that the e-mail transmission has failed, a paper copy of the Notice will be provided to the individual. [45 CFR 164.520(c)(3)(ii)]

When requested, Northern Health Centers, Inc. will provide a paper copy to an individual who is the recipient of an electronic Notice. [45 CFR 164.520(c)(3)(iv)]

Process for Providing Notice for Providers with a Direct Treatment Relationship
If Northern Health Centers, Inc. has a direct treatment relationship with an individual, Northern Health Centers, Inc. will provide the Notice:

  • No later than the date of the first delivery of service, including service delivered electronically to such individual after the compliance date; or [45 CFR164.520(c)(2)(i)(A)]
  • In an emergency situation as soon as reasonably practicable after the emergency treatment situation. Document the emergency situation and the inability to obtain the individual’s written acknowledgement. Refer to Written Acknowledgement form [45 CFR 164.520(c)(2)(i)(B)]
  • Electronically if the first service of delivery to an individual is electronic. [Northern Health Centers, Inc.] will provide electronic Notice automatically and contemporaneously in response to the individual's first request for service. [45 CFR 164.520(c)(3)(iii)]

    • Written Acknowledgement of Receipt of Notice by Direct Treatment Providers
    If Northern Health Centers, Inc. has a direct treatment relationship with the individual, Northern Health Centers, Inc. will make a good faith effort to obtain a written acknowledgement of receipt of the Notice. Obtaining a written acknowledgement is not required in an emergency treatment situation. However, the acknowledgement will be obtained as soon as reasonably practicable after the emergency treatment situation. Refer to Written Acknowledgement form. If the acknowledgement was not obtained, Northern Health Centers, Inc. will document its good faith efforts to obtain the acknowledgement and the reason why it was not obtained. [45 CFR 164.520(c)(2)(ii)] Refer to Written Acknowledgement form.

    Northern Health Centers, Inc. will maintain the documentation of the written acknowledgement, the deferred acknowledgement due to an emergency treatment situation and/or that the acknowledgement was not obtained and the reason it was not obtained.

    If Northern Health Centers, Inc. maintains a physical service delivery site, Northern Health Centers, Inc. will:

  • Have the Notice available at the delivery site for the individual to request to take with them; and
  • Post the Notice in a clear and prominent location where it is reasonable to expect the individual to be able to read the Notice. [45 CFR 164.520(c)(2)(iii)]

    • If Northern Health Centers, Inc. revises the Notice, Northern Health Centers, Inc. will make the Notice available upon request on or after the effective date of the revision and promptly comply with the requirements of the federal privacy rule. [45 CFR 164.520(c)(2)(iv)]

    Electronic Notice
    If Northern Health Centers, Inc. maintains a web site that provides information about their customer services or benefits, Northern Health Centers, Inc. will prominently post its Notice on the web site and make the Notice available electronically through the web site. [45 CFR 164.520(c)(3)(i)]

    Northern Health Centers, Inc. may provide the Notice to an individual by e-mail, if the individual agrees to electronic Notice and the agreement has not been withdrawn. If Northern Health Centers, Inc. knows that the e-mail transmission has failed, a paper copy of the Notice will be provided to the individual. [45 CFR 164.520(c)(3)(ii)]

    When requested, Northern Health Centers, Inc. will provide a paper copy to an individual who is the recipient of an electronic Notice. [45 CFR 164.520(c)(3)(iv)]

    Administrative Responsibilities

    Review of the Notice
    Optional: Northern Health Centers, Inc.]’s [Sheila Kummers] will review the Notice annually or as needed to ensure compliance with the federal privacy rule.

    Revisions to the Notice in Relation to Changes to a Privacy Practice
    To enable Northern Health Centers, Inc. to make changes in a privacy practice that is stated in the Notice, the Notice will contain a statement that Northern Health Centers, Inc. reserves the right to make changes in its privacy practices. [45 CFR 164.530(i)(2)(ii)]

    If Northern Health Centers, Inc. makes a change to the Notice, Northern Health Centers, Inc. will promptly make the appropriate revisions to the Notice and make the revised notice available in accordance with the federal privacy rule. [45 CFR 164.530(i)(4)(i)(C)]

    If the Notice does not contain a statement reserving the right of Northern Health Centers, Inc. to change a privacy practice that is stated in the Notice, Northern Health Centers, Inc. is bound by the privacy practices as stated in the Notice with respect to protected health information created or received while the notice is in effect. [45 CFR 164.530(i)(4)(ii)]

    Northern Health Centers, Inc. may change a privacy practice and the related policies and procedures without having reserved the right to do so provided that:

  • Such change meets the implementation requirements under the Administrative Requirement standard that allows a change in a privacy practice under the federal privacy rule; and
  • The change is only effective with respect to protected health information created or received after the effective date of the Notice. [45 CFR 164.530(i)(4)(ii)(A-B)]

    • Revisions to the Notice
    Northern Health Centers, Inc. will promptly revise and distribute its Notice whenever there is a material change to:

  • The uses or disclosures;
  • The individual's rights;
  • Northern Health Centers, Inc.'s legal duties; or
  • Other privacy practices stated in the Notice. [45 CFR 164.520(b)(3)]

    • Except when required by the federal privacy rule, a material change to any term of the Notice may not be implemented prior to the effective date of the Notice in which the material change is reflected. [45 CFR 164.520(b)(3)]

    Employee Education (Optional)
    Employees will be trained on the policies and procedures related to the Notice of Privacy Practices. Refer to Staff Education Policy.

    Documentation
    Northern Health Centers, Inc. will file a copy of the original Notice and a copy of all revised Notices in Northern Health Centers, Inc.’s compliance file. If the Notice is in writing or electronic, Northern Health Centers, Inc. will retain a copy of the written or electronic Notice in Northern Health Centers, Inc.’s compliance file. [45 CFR 164.520(e)]

    Note: Northern Health Centers, Inc. is not required to file a copy of the Notice in the patient’s chart.

    If Northern Health Centers, Inc. is a direct treatment provider, Northern Health Centers, Inc. will retain any written acknowledgements of receipt of the Notice or documentation of good faith efforts to obtain such written acknowledgement. [45 CFR 164.520(e)]

    The documentation will be maintained for six years from the date of its creation or the date when it was last in effect, whichever is greater. [45 CFR 164.530(j)]

    Note: Health care providers and other covered entities that participate in an organized health care arrangement (OHCA) may use a single, joint notice that covers all of the participating covered entities provided that the conditions in the federal privacy rule are met. Where a joint notice is provided to an individual by any one of the covered entities to which the joint notice applies, the Privacy Rule's requirements for providing the notice are satisfied by all others covered by the joint notice. If the joint notice is provided to an individual by a direct treatment provider participating in the OHCA, the provider must make a good faith effort to obtain the individual's written acknowledgement of receipt of the joint notice according to the Office for Civil Rights privacy rule guidance dated December 3, 2002.