Privacy Practices
MINNESOTA NOTICE FORM
Notice of
Psychologist's Policies and Practices to Protect the Privacy of Your
Patient's Health Information
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.
I. Uses and Disclosures for Treatment, Payment, and
Health Care Operations
We may use or disclose your protected health information (PHI), for treatment, payment,
and health care operations purposes with your consent. To help clarify these terms, here
are some definitions:
- PHI refers to information in your health record that
could identify you.
- Treatment, Payment, and Health Care Operations
- Treatment is when we provide, coordinate or manage your health care and other services
related to your health care. An example of treatment would be when we consult with another
health care provider, such as your family physician or another psychologist.
- Payment is when we obtain reimbursement for your healthcare. Examples of payment are
when we disclose your PHI to your health insurer to obtain reimbursement for your health
care or to determine eligibility or coverage. Continued
