This notice describes how clinical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

In accordance with the Health Insurance Portability and Accountability Act (HIPPA), MAP Behavioral Health Center is required to provide you with information regarding our responsibilities to you in how your psychological and medical information (protected health information, referred to as PHI) may be used and disclosed, and how you might access this information. This notice is intended to clarify these responsibilities and rights. Please ask us if you have further questions regarding the use or disclosure of your PHI.

For Your Treatment

MAP Behavioral Health Center may use or disclose your protected health information in order to provide treatment to you. This includes situations when our providers share information about you internally for case coordination, or when they work with external providers to write or order a prescription, perform lab testing or otherwise help carry out your treatment services.

For Payment

MAP Behavioral Health Center may use or disclose your PHI in order to bill you, your insurance company or a member of your family for charges related to treatment and services that we provide to you. For instance, when we submit a claim to your insurance company for reimbursement, we must provide some details regarding your treatment to verify eligibility and coverage.

For Our Health Care Operations

We may use or disclose your PHI as part of our other operational procedures such as quality improvement, performance evaluation and compliance reviews. An example of using your information for our operations purposes would be to review the care provided to you to evaluate its effectiveness, efficiency and quality. We may also use information on the care provided to you for business planning, workforce planning and budget management.

With Your Authorization

To use or disclose your health information for any reason other than those stated in this notice, we will need a written authorization from you. Authorization can be provided using the MAP Behavioral Health Center’s Authorization for Release of Protected Health Information form and will specify the entity to which you were authorizing disclosure, which information you’re authorizing us to disclose, and the purpose of the disclosure to that entity.

Other Unique Situations

  • In cases of child abuse-if we know or have reason to suspect that a child is being neglected or abused, or that a child has been neglected or abused within the preceding three years, we must immediately report this to the local welfare agency, police or sheriff’s department. We may need to disclose PHI to adequately and accurately report the abuse.
  • Public health activities- we may use or disclose PHI to the appropriate entities or authorities responsible for insuring public health. Examples of this include reporting a negative reaction or problem resulting from a drug to the FDA or notification to the Center for Disease Control and Prevention (CDC) of exposure to a communicable disease when notification is required.
  • Research- MAP Behavioral Health Center may use or disclose PHI for research purposes under certain limited circumstances. We will obtain written authorization from you in these cases unless an Internal Review Board has determined that your authorization may be waived; this may only happen if the following conditions have been met:
    • The disclosure involved no more than a minimal risk to your privacy as demonstrated by a plan to protect and destroy identifying information at the earliest opportunity, and written assurances that PHI will not be re-used.
    • The research could not be conducted without the waiver.
    • The research could not be conducted without the use of PHI.
  • For purposes of health oversight activities-state regulatory agencies may subpoena records from us that include PHI if they’re relevant to an investigation being conducted as part of oversight activities of the healthcare system or government programs.
  • Serious threat to health or safety–we may use and disclose your PHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or to the public. We must also do so if a member of your family or someone who knows you well has reason to believe that you present an imminent threat of harm to yourself or others. Under the circumstances, we will only make disclosures to a person or organization able to help prevent the threat.
  • Business associates–we will share your PHI with business associates that assist MAP Behavioral Health Center in business and other administrative operations. Business associates include people or companies outside of MAP Behavioral Health Center who provide services to us. For example, health information may be disclosed by MAP Behavioral Health Center to a vendor to send statements and process payment for services rendered. MAP’s business associates must comply with HIPPA laws and we have agreements with them to protect the privacy and security of your PHI.


You have the following rights related to your protected health information privacy.

Right to Request Restrictions

You have the right to request restrictions on certain uses and disclosures of protected health information. If you have paid your healthcare provider in full for a particular healthcare service or item and specifically request that we do not disclose information about this healthcare item or service to your health plan for payment or healthcare operations purposes, we will agree to this request. Federal law states that we are not otherwise required to agree to your request. If we do agree, however, we are bound to and will comply with your request unless otherwise required by law or in order to treat you. To request a restriction, you must provide us, in writing:

  1. What information you want to limit;
  2. Whether you want to limit our use, disclosure or both;
  3. To whom you want the limits to apply.

Right to Receive Confidential Communications

You have the right to request and receive confidential communications about your health, treatment or related issues in a particular matter or at a certain location. Four instance, you may prefer us to contact you at your home phone number rather than your work phone number. MAP Behavioral Health Center will accommodate all reasonable requests.

Right to Inspect and Copy

You have the right to inspect or obtain a copy (or both) of PHI -  not including psychotherapy notes–that is used to make treatment decisions about you for as long as the PHI is maintained in our records. We may deny you access to PHI under certain circumstances, but in those cases, you may have this decision reviewed. On your request, we’ll discuss with you the details of this process.

Right to Amend

If you feel the health information we have about you is incorrect or incomplete, you may ask us to amend the information as long as the information is kept on file. Your request must include a reason to support the amendment and you will be notified in writing if your request is denied. If it is denied, you have the right to submit a written statement of your disagreement with the denial which will be appended or linked to the PHI in question.

Right to an Accounting of Disclosures

You have the right to receive a list of disclosures we have made of your PHI for purposes other than routine treatment, payment or operations activities. Your request must state a time period that is not longer than six years.

Right to Receive Breach Notification

If MAP Behavioral Health Center or any of its business associates experience a breach of your health information (as defined by HIPPA laws) that compromises the security or privacy of your health information, you’ll be notified of the breach and about any steps you should take to protect yourself from potential harm resulting from the breach.

Right to a Paper Copy

You have the right to obtain a paper copy of this notice from MAP Behavioral Health Center upon request at any time.


Map Behavioral Health Center is required by law to maintain the privacy of protected health information and to provide you with this notice of our legal duties and privacy practices with respect to PHI. 

We reserve the right to change our policies and practices regarding how we use or disclose PHI, or how we will implement patient rights concerning PHI. We reserve the right to change this notice and to make provisions in our new notice effective for all information we maintain. If we change these practices, we will publish a revised Notice of Privacy Practices. This revised notice will be posted and available at our places of service and on our website at

Complaints and the other questions

If you are concerned that we have violated your privacy rights or you disagree with the decision that we made about access to your records, you may make a complaint to the MAP Behavioral Health Center’s Privacy Officer or make a written complaint to the Secretary of the Department of Health and Human Services. You will not be penalized for filing a formal complaint. You may also call MAP Behavioral Health Center’s Privacy Officer at 218-461-8107 to discuss your complaint or any privacy-related questions you may have.


Notice of Private Practices: You have the right to read our Privacy Practices before you decide whether or not to sign this consent. A copy of our Notice and/or this consent is available upon request. Our Notice provides a description of our treatment, payment activities and healthcare operations, of the uses and disclosures we make of your protected health information. 

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations. 

I have been shown a copy of this office’s Notice of Privacy Practices and have had full opportunity to read and consider its contents. I understand that by signing this consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations. 

If this consent is signed by a personal representative on behalf of the patient, complete the following:

Name *
I am 18 years of age or older. *
Date Of Birth *
Date Of Birth
If Under 18: Parent / Guardian Name
If Under 18: Parent / Guardian Name
Date Today *
Date Today
Signature *