Notice of Privacy Practices for Protected Health Information

This notice describes how medical information about you may be used and disclosed and how you can get access to this information.  Please review it carefully! This practice (Nancy Arikian, Ph.D., L.P.) is committed to treating and using protected health information about you responsibly. This Notice of Health Information Practices describes the personal information that I collect, and how and when I use or disclose that information. It also describes your rights as they relate to your protected health information. This Notice is effective April 14, 2003 and applies to all protected health information as defined by federal regulations. This practice is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations. Protected health information is information that relates to:

  • The past, present, or future physical or mental health condition of an individual;
  • The provision of health care to an individual, or the past, present, or future payment for the provision of health care to an individual;
  • Information that identifies the individual or could reasonably be used to identify the individual


Treatment is the provision, coordination, or management of health care and related services by one or more health providers. This includes consultation between health care providers relating to a patient or the referral of a patient from one health care provider to another. Examples of uses of your health information for treatment purposes are:

  • A nurse or doctor obtains treatment information about you and records it in a health record.
  • During the course of your treatment, the clinician determines he/she will need to consult with another specialist in the area. He/she will share the information with such specialist and obtain his/her input.


For psychologists, payment refers to activities related to obtaining reimbursement for health care services that have been provided. These activities may include determinations of eligibility for coverage, billing, claims management, collection activities, and utilization review. Example of use of your health information for payment purposes:

  • I submit a request for payment to your health insurance company. The health insurance company (or other business associate helping me to obtain payment) requests information from me regarding medical care given. I will provide information to them about you and the care given.

Health Care Operations

This is a broad category of activities that may range from quality assessment and utilization review to conducting or arranging for medical reviews, legal services and auditing, business planning, and administrative services. Example of use of your information for health care operations:

  • I obtain services for my insurers or other business associates for outcome evaluation. I will share information about you with such insurers or other business associates as necessary to obtain these services.

Understanding Your Health Record/Information

Each time you visit my practice, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:

  • Basis for planning your care and treatment;
  • Means of communication among health professionals who contribute to your care (if they are authorized to obtain access to your record);
  • Legal document describing the care you received;
  • Means by which you or a third-party payer can verify that services billed were actually provided;
  • A source of information for public health officials charged with improving the health of this state and nation;
  • A source of data for my planning and marketing;
  • A tool with which I can assess and continually work to improve the care that I provide and the outcomes achieved.

Understanding what is in your record and how your health information is used helps you to ensure its accuracy; better understand who, what, when, where, and why others may access your health information; and make more informed decisions when authorizing disclosure to others.

Your Health Information Rights

The health and billing records I maintain are the physical property of the office/hospital. The information in it, however, belongs to you. You have a right to:

  • Request a restriction on certain uses and disclosures of your health information by delivering the request to my office — I am not required to grant the request, but I will comply with any request granted;
  • Obtain a paper copy of the current Notice of Privacy Practices for Protected Health Information (‘Notice”);
  • Request that you be allowed to inspect and copy your health record and billing record – you may exercise this right by delivering the request to my office/hospital;
  • Appeal a denial of access to your protected health information, except in certain circumstances;
  • Request that your health care record be amended to correct incomplete or incorrect information by delivering a request to my office/hospital. I may deny your request if you ask me to amend information that:
    • Was not created by me, unless the person or entity that created the information is no longer available to make the amendment;
    • Is not part of the health information kept by or for the office/hospital;
    • Is not part of the information that you would be permitted to inspect and copy; or,
    • Is accurate and complete.

If your request is denied, you will be informed of the reason for the denial and will have an opportunity to submit a statement of disagreement to be maintained with your records;

  • Request that communication of your health information be made by alternative means or at an alternative location by delivering the request in writing to my office/hospital;
  • Obtain an accounting of disclosures of your health information as required to be maintained by law by delivering a request to my office/hospital. An accounting will not include uses and disclosures of information for treatment, payment, or operations; disclosures or uses made to you or made at your request; uses or disclosures made pursuant to an authorization signed by you; uses or disclosures made in a facility directory or to family members or friends relevant to that person’s involvement in your care or in payment for such care; or, uses or disclosures to notify family or others responsible for your care of your location, condition, or your death.
  • Revoke authorizations that you made previously to use or disclose information, except to the extent that action has already been taken, by delivery of a written revocation to my office/hospital.

If you want to exercise any of the above rights, please inform Nancy Arikian, Ph.D., L.P., in person or in writing. She will inform you of the steps that need to be taken to exercise your rights.

Nancy Arikian, Ph.D., L.P.
1409 Willow Street, Suite 410
Minneapolis, Minnesota 55403

My Responsibilities

Nancy Arikian, Ph.D., L.P. is required to:

  • Maintain the privacy of your health information as required by law;
  • Provide you with a notice as to my duties and privacy practices with respect to the information I collect and maintain about you;
  • Abide by the terms of this Notice;
  • Notify you if I am unable to agree to a requested restriction;
  • Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.

I reserve the right to change my privacy practices and to make the new provisions effective for all protected health information I maintain. If my information practices change, I will amend this Notice and mail a revised notice to the address you’ve supplied to me, or if you agree, I will email the revised notice to you. I will not use or disclose your health information without your authorization, except as described in this Notice. I will also discontinue using or disclosing your health information after I have received a written revocation of the authorization from you according to the procedures included in the authorization.

For More Information or to Report a Problem

If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact the Privacy Officer, Nancy Arikian, Ph.D., L.P., at 612-353-5414. If you believe your privacy rights have been violated, you may file a written complaint with the Privacy Officer listed above or with the Office for Civil Rights, U.S. Department of Health and Human Services. There will be no retaliation against you for filing a complaint. The address for filing a complaint is listed below:

Office for Civil Rights
U.S. Dept. of Health and Human Services
233 N. Michigan Avenue, Suite 240
Chicago, IL 60601

Other Disclosures and Uses of Protected Health Information

Communication with Family – Using my best judgment, I may disclose to a family member, other relative, close personal friend, or any other person you identify verbally or in writing, health information relevant to that person’s involvement in your care or in payment for such care. Under non-emergency circumstances, I will ask for your consent in writing.

Notification – Unless you object, I may use or disclose your protected health information to notify, or assist in notifying, a family member, personal representative, or other person responsible for your care, about your location, and about your general condition, or your death.

Research – I may disclose information in my own research or to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.

Disaster Relief – I may use and disclose your protected health information to assist in disaster relief efforts.

Workers Compensation – If you are seeking compensation through Workers Compensation, I may disclose your protected health information to the extent necessary to comply with laws relating to Workers Compensation.

Public Health – As authorized by law, I may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability; to report reactions to medications or problems with products; to notify people of recalls; and to notify a person who may have been exposed to a disease or who is at risk for contracting or spreading a disease or condition.

Abuse and Neglect – I may disclose your protected health information to public authorities as allowed by law to report abuse or neglect.

Employers – I may release health information about you to your employer if I provide health care services to you at the request of your employer, and the health care services are provided either to conduct an evaluation relating to surveillance of the workplace or to evaluate whether you have a work-related illness or injury. In such circumstances, I will give you written notice of such release of information to your employer. Any other disclosures to your employer will be made only if you provide a specific authorization for the release of that information to your employer.

Correctional Institutions – If you are an inmate of a correctional institution, I may disclose to the institution or its agents the protected health information necessary for your health and the health and safety of other individuals.

Law Enforcement – I may disclose your protected health information for law enforcement purposes as required by law, such as when required by a court order, or in cases involving felony prosecution.

Health Oversight – Federal law allows me to release your protected health information to appropriate health oversight agencies or for health oversight activities.

Judicial/Administrative Proceedings – I may disclose your protected health information in the course of any judicial or administrative proceeding as allowed or required by law, with your authorization, or as directed by a proper court order.

Serious Threat – To avert a serious threat to health or safety, I may disclose your protected health information consistent with applicable law to prevent or lessen a serious, imminent threat to the health or safety of a person or the public.
For Specialized Governmental Functions – I may disclose your protected health information for specialized government functions as authorized by law such as to Armed Forces personnel, for national security purposes, or to public assistance program personnel.

Marketing – I may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Other Uses – Other uses and disclosures, besides those identified in this Notice, will be made only as otherwise required by law or with your written authorization and you may revoke the authorization as previously provided in this Notice under “Your Health Information Rights.”

Website – If I maintain a website that provides information about my practice, this Notice will be on the website.

HIPPA Notice of Privacy – 06/10/2015