Notice of Privacy Practices

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.

What is this Notice for?
The Notice of Privacy Practices tells you about your rights under a federal law called the Health Insurance Portability and Accountability Act (“HIPAA”) and other federal and state privacy laws. The laws protect your medical information and set rules about who can see it and get access to it.

What is your information?
In this Notice, when we use the term “Medical Information,” we mean information that identifies you and relates to your health or condition, your health care services, or payment for those services. It includes health information (like diagnosis and treatment plans) and demographic information (like your name, address, phone number, and date of birth). It also includes any information, whether oral, electronic, or paper, which is created or received by Essentia Health and is related to your health care or payment for the provision of medical services. It specifically includes substance use, tobacco and caffeine use, sickle cell anemia, HIV or AIDS, communicable diseases, and genetic information, if such information exists.

The information documenting the care and services you receive from Essentia Health is contained in a medical record, which is the property of Essentia Health. We need this medical record to provide you with quality care, bill for your care, and meet legal requirements.

Why are you getting this Notice?
Your privacy is important to us. The law requires that you be given a copy of this Notice so that you can:

• know your rights;
• use your rights;
• ask questions about your rights;
• file a complaint if you think your rights may have been violated; and
• know that we will notify you if we become aware of a breach of your information.

Who will follow this Notice?
This Notice applies to the Medical Information created or received by Essentia Health and all affiliated clinics, departments, hospitals, programs, and entities, including our staff, business associates, and agents (collectively referred to as “Essentia Health”). You can find a list of current Essentia Health locations at Essentia locations.

Use and Disclosure of Your Health Information
To provide you with the most comprehensive and high-quality care, we will need to use and disclose your Medical Information. When we use and disclose your Medical Information, we will follow the applicable law and take steps to protect your information.

Your Medical Information may be used and disclosed for the following purposes:

Treatment, Payment, and Health Care Operations
Treatment: We use and share your Medical Information to treat you. We share it with other professionals and non-Essentia organizations that treat you or manage your care. This makes your care safe and coordinated.

Example:

• Your primary care physician may tell a specialty doctor who is treating you what medicines you’re taking. This prevents dangerous drug interactions.
• After orthopedic surgery, your doctor may refer you for rehabilitation. Information will be shared between caregivers to ensure continuity of care.
• We may share and access your current prescription history for controlled substances in state databases.

Payment: We use and share your Medical Information to bill and get paid by health plans and other payers for care that you receive.

Example:

• We may give your health plan information about the services you receive, so it will pay us, or reimburse you, for those services.
• We may contact your health plan to see if a service is covered before we provide that care.

Health Care Operations: We may use and share your Medical Information to help run our organization and make sure that all of our patients are receiving quality care.

Example:

• We may use your Medical Information to improve the quality of care and patient experience and to manage Essentia Health’s business operations. This includes sharing your information with accrediting and quality organizations, payers, accountable care organizations, regulatory agencies, public health agencies that are responsible for licensing and accreditation, fraud investigation, care management, immunization tracking, public health reporting, drug and device defects or recalls, and quality evaluation.
• We may share your Medical Information with our business associates - those we partner with to provide services on our behalf but who aren’t our employees or affiliates. These partners are required by law to safeguard your information the same way we do.

Additional applicable state law requirements: Minnesota law generally requires your consent before we share your Medical Information outside of Essentia Health for treatment, payment and health care operation purposes. This consent may be obtained via the Essentia Health General Consent & Authorization. Please note that we are not required to obtain your permission to share your information in a medical emergency if you can’t give us permission due to your condition.

Shared Electronic Health Records: We may share your Medical Information with other health care providers and facilities by permitting them to access relevant portions of our electronic health record (“EHR”) – whether on their own behalf or on behalf of Essentia Health – for purposes of treatment, payment, and health care operations. In some cases, these providers and facilities may also be able to update the Medical Information stored on our EHR. A shared EHR helps us and other members of your care team, including those outside of Essentia Health, better understand your medical history and current concerns and treatment, and can result in improved care coordination and treatment outcomes.

Health Information Exchange: We may make your Medical Information available electronically through an electronic health information exchange to other health care providers that request your information to care for you. For example, if you visit another healthcare provider’s emergency department, they can access your Essentia Health records. In all cases, the requesting provider must have or have had a treatment relationship with you. Participation in an electronic health information exchange also lets us see other providers’ information about you so we can treat you. If you do not want to participate in the health care exchange, you can choose to opt out on the General Consent & Authorization form or by contacting the Essentia Health, Health Information Management Department.

Artificial Intelligence Tools: We may use artificial intelligence (AI) tools to support a variety of our services, such as our treatment, payment, and health care operations functions. For example, we may use AI tools to assist with medical transcription. However, these tools are designed to support, not replace, the expertise and judgment of our healthcare providers.

Phone Calls, Text Messages, and Email: Essentia Health may use the contact information you provide to us to reach you and send you information. Essentia Health may use an automated telephone dialing system, may utilize pre-recoded or artificial voices, and/or send text or email messages for treatment, payment, health care operations and other notification purposes, including appointment or prescription reminders, care coordination, billing, surveys, research, marketing and fundraising. These communication methods are not secure, and there is some risk that information delivered by these methods could be read by a third party. You can opt out of these messages. You are responsible for providing current contact information. To learn more about terms and conditions and opting out, you may visit essentiahealth.org.

Marketing: In general, Essentia Health must get your written authorization before using your health information for marketing purposes.

Without your written authorization, we can:

• give you marketing materials in a face-to-face encounter;
• tell you about products or services relating to your treatment;
• communicate with you to coordinate or manage your care; and
• give you information about different treatments, providers or care settings.

Hospital Directory: While you are a patient at Essentia Health, friends, family and others may call to ask about you. If someone calls and asks for you by name, we will tell them your location so that they may call or visit you. If you wish to opt out, inform a staff member during registration. If you are a patient receiving services from a Part 2 Program (as defined herein), we will obtain your consent prior to disclosing your presence at the facility.

Information to Faith Leaders: Faith leaders sometimes request a list of members of their religion that are hospitalized so they can offer visits and provide spiritual support. You can choose to opt out from inclusion on this list on the General Consent & Authorization. You will still be listed on the hospital directory and faith leaders can ask for you by name unless you inform a staff member during registration that you don’t want to be included in the hospital directory.

Fundraising: Essentia Health and/or an Essentia Health business associate may contact you about supporting our fundraising efforts, programs and events to support our mission. We may use certain information (name, date of birth, address, email address, telephone number, dates of service, age, gender, department of service, treating physician, outcome information and health insurance status) to contact you in the future to raise money for Essentia Health.

We do not sell or rent patient names or contact information to organizations outside Essentia Health without your authorization.

If, upon receiving a fundraising communication, you wish to opt-out from receiving further fundraising communications, please refer to the opt-out instructions provided in the letter or form sent to you.

Research:: Conducting research is an important part of Essentia Health’s mission. Research projects conducted by Essentia Health must be approved through a special review process to make sure patient safety, welfare, and confidentiality are protected. We may use and disclose Medical Information about our patients for research purposes only as permitted by applicable law. In some instances, federal law allows us to use your Medical Information for research without your authorization, provided we get approval from an institutional review or privacy board or when determining whether the study or the potential participants are appropriate. Your treatment and welfare will not be affected, and your information will be protected. You may opt out of your Medical Information being used for research by updating your Research Studies-Participation Preferences in MyChart or calling 218-786-3940 or 1-877-710-1094.

Additional applicable state law requirements: Minnesota law generally requires patient consent for disclosure of Medical Information by Essentia Health’s Minnesota entities to outside researchers for research purposes. Essentia Health’s Minnesota entities will obtain consent from their patients or will make a good faith effort to obtain consent before releasing Medical Information to an external researcher. Wisconsin law generally requires patient consent before we may disclose Medical Information for research purposes to a researcher who is not affiliated with Essentia Health. In some situations, we may disclose Medical Information for research purposes to a researcher who agrees to protect the privacy of your information.

Family Members and/or Support Person(s) Involved in Your Care: Essentia Health may disclose relevant Medical Information to a family member or support person who is involved in your care with your consent and as permitted by law. We find that many patients want us to discuss their care with family members and support person(s) to help them understand their care, to help handle their bills, or to help schedule their appointments. Essentia Health may also disclose your Medical Information to a personal representative who has the legal authority to make health care decisions on your behalf if you are unable to. If a family member or support person is present while care is being provided, Essentia Health will assume your companion(s) may hear the discussion, unless you state otherwise. In a disaster situation, we also may disclose relevant Medical Information to disaster relief organizations to help locate your family members or others to inform them of your location, condition, or death.

To Prevent a Serious Threat to Health or Safety: We may use and disclose Medical Information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. To Prevent a Serious Threat to Health or Safety: We may use and disclose Medical Information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.

To Business Associates: Some services are provided by or to Essentia Health through contracts with business associates. Examples include Essentia Health’s, attorneys, consultants, collection agencies, and accreditation organizations. We may disclose your Medical Information to our business associates so that they can perform the job we have contracted with them to do. To protect the information that is disclosed, each business associate is required to sign an agreement to appropriately safeguard the information and not to redisclose the information unless specifically permitted by law.

Your Medical Information may also be released in the following special situations:

Organ and Tissue Donation: If our health care professionals find that you may be a candidate to donate organs or tissue, consistent with applicable law, we may disclose your Medical Information to health care providers, organizations or other entities involved in the procurement, banking or transplantation of organs/tissue. The information that Essentia Health may disclose is limited to the information necessary to make a transplant possible.

Military Authorities/National Security: When required by law or with patient consent, Essentia Health may release Medical Information to authorized federal officials for military, intelligence, counterintelligence or other national security activities. Essentia Health may also disclose protected health information to authorized federal officials so they may provide protection to the President or other authorized persons, or foreign heads of state, or conduct special investigations only as required by law or with your written consent.

Workers’ Compensationy: If you are seeking workers' compensation for a work-related illness or injury, we may release Medical Information related to your claim, as permitted or authorized by the state Workers' Compensation program.

Public Health Purposes:We may disclose Medical Information about you for legally authorized or required public health activities. Examples include, but are not limited to:

• preventing or controlling disease;
• injury or disability;
• reporting births and deaths;
• reporting reactions to medications or problems with products;
• notifying people of recalls of products they may be using;
• notifying a person who may have been exposed to a communicable disease or may be at risk for contracting or spreading a disease or condition.
• reporting child abuse or neglect, or abuse of a vulnerable adult; or
• reporting to the FDA as permitted or required by law.

We may report your immunizations to state immunization databases. These confidential databases make it easy to keep track of immunizations and ensure you get the right immunization at the right time. You may contact your state’s immunization database if you wish to opt out.

Additional applicable state law requirements: Wisconsin law allows a physician or optometrist to report a patient’s name and other information relevant to the patient’s condition to the Wisconsin Department of Transportation. The physician may do so without the patient’s permission, if he/she believes that the patient’s condition affects their ability to safely operate a motor vehicle. If you receive services in Wisconsin for mental illness, developmental disabilities, alcoholism, or drug dependence, you can inspect and get a copy of the information being shared, if required by Wis. Admin. Code DHS 92.05 & 92.06

Minnesota law allows a physician to report a patient’s name and information about their physical or mental condition to the Minnesota Department of Public Safety. The physician may do so without the patient’s permission, if he/she believes that the patient’s condition affects their ability to safely operate a motor vehicle.

Health Oversight Activities: We may disclose Medical Information for health oversight activities as authorized by law. Examples of oversight activities include audits, investigations, inspections, and licensing. These activities are needed for the government to oversee the health care system, government programs, and compliance with civil rights laws.

Judicial and Administrative Proceedings: We may disclose your Medical Information in the course of any judicial or administrative proceeding as required or permitted by law, including in response to a court or administrative order, subpoena of a substitute medical decision-making board, a grand jury subpoena, or with your written consent. We may disclose information in the context of civil litigation where you have put your condition at issue in the litigation.

Law Enforcement: : We may share the minimum necessary Medical Information with governmental authorities, including law enforcement, social services or protective services agencies:

• with patient consent or authorization;
• in response to a court order, grand jury subpoena, warrant, summons or similar lawful process;
• to locate a missing person;
• to report certain types of wounds, such as gunshot wounds and some burns.
• to report abuse, neglect, or maltreatment of a child or vulnerable adult;
• in other situations, as required or permitted by law.

If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose your health information to the institution or agents if it is needed for your health and the health and safety of other individuals, in accordance with state and federal requirements.

Additional applicable state law requirements: Minnesota and Wisconsin law generally require patient consent for disclosures of Medical Information by Essentia Health entities for law enforcement purposes, unless the disclosure is required by law or in response to a valid court order or warrant.

Required by Law: We will use or disclose your Medical Information when required by federal, state, or local laws. For example, Essentia Health is required to report:

• certain gunshot wounds and other injuries that may have resulted from an unlawful act
• abuse or neglect of a child or vulnerable adult.

Coroner, Medical Examiner or Funeral Director: We will release Medical Information to a coroner or medical examiner in the case of certain types of death, and we must disclose Medical Information upon the request of the coroner or medical examiner. This may be necessary, for example, to identify you or determine the cause of death. We may also release the fact of death and certain demographic information about you to funeral directors as necessary to carry out their duties.

Additional applicable state law requirements: Minnesota law generally requires the consent of a patient’s authorized family or legal representative for disclosure of Medical Information to funeral directors. Wisconsin law generally requires consent of a patient’s authorized family or legal representative to release health information to funeral directors. However, HIV test results and certain other health information may be disclosed to a funeral director when necessary to permit the funeral director to carry out his/her duties.

Safety & Security: Video surveillance and monitoring is used for patient and staff safety and security. Essentia Health follows its policies to protect patient privacy. Essentia Health follows its policies to protect patient privacy.

Medical Information with Additional Protections: Certain types of Medical Information may have additional protection under federal or state law. For example, HIV/AIDS and genetic testing results have additional protections under certain state laws. In many circumstances, Essentia Health would need to get your written consent before disclosing that information to others.

Confidentiality of Substance Use Disorder Patient Records: Certain Essentia Health facilities, units, and/or staff specialize in providing substance use disorder treatment (“Part 2 Programs”). The confidentiality of substance use disorder patient records maintained by these Part 2 Programs may be protected by special federal law and regulations, in addition to HIPAA.

If we receive or maintain any information about you from a substance use disorder treatment program that is covered by the regulations at 42 CFR Part 2 under a general consent you gave to the Part 2 Program to use and disclose the Part 2 Program record for purposes of treatment, payment or health care operations, we may also use and disclose your Part 2 Program record for treatment, payment and health care operations purposes as described in this Notice. However, if we receive or maintain your Part 2 Program record under a specific consent you provide to us or another third party, we will use and disclose your Part 2 Program record only as expressly permitted by you in the specific consent.

We will not use or disclose your Part 2 Program record, or testimony that describes the information contained in your Part 2 Program record, in any civil, criminal, administrative, or legislative proceedings by any Federal, State, or local authority, against you, unless authorized by your consent or the order of a court after it provides you notice of the court order.

We may disclose Medical Information about you with those personnel within the criminal justice system who have made participation in the Part 2 Program a condition of the disposition of any criminal proceedings against you or of your parole or release from custody, if the disclosure is made to only those who have a need to know the information in connection with their duty to monitor your progress and we have obtained your patient consent. Your consent will be obtained on the Essentia Health Release of Information form. You can revoke this consent in writing at any time.

Generally, a Part 2 Program may not say to a person outside the Part 2 Program that a patient receives or has received services by the Part 2 Program, or disclose any information identifying a patient as having or having had a substance use disorder unless:

1. The patient consents in writing;
2. The disclosure is allowed by a court order; or
3. The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit or program evaluation.
4. For substance use disorder records specially protected by 42 CFR Part 2, these records may be redisclosed by the recipient and no longer specially protected by 42 CFR Part 2, except that HIPAA Covered Entity and Business Associate recipients must still comply with 42 CFR Part 2’s requirements restricting the use of substance use disorder records in civil, criminal, administrative, and legislative proceedings against the patient.

Uses & Disclosures With Your Authorization<>: We may only use or disclose your Medical Information with your written permission except as described in this Notice or specifically required or permitted by law.

If you give written permission, you have the right to withdraw your permission for future uses and disclosures by notifying Essentia Health in writing.

You have the following rights regarding Medical Information we maintain about you:

Right to View and Copy: You have the right to request, in writing, to view and get a copy of the Medical Information that we use to make decisions about your care. You have the right to ask the copy be provided in an electronic form or format (e.g., PDF saved onto a thumb drive). If the requested form or formats are not easy to produce, we will work with you to provide it in a reasonable electronic form or format. Essentia Health generally may charge a reasonable, cost-based fee to cover the expense of copying, mailing, or other supplies associated with your request, to the extent permitted by state and federal law. If we maintain your Medical Information electronically as part of a designated record set, you have the right to receive a copy of your Medical Information in electronic format upon your request. You may also direct us to transmit your Medical Information (whether in hard copy or electronic form) directly to an entity or person clearly and specifically designated by you in writing.

We may deny your request to inspect and copy your information in certain very limited circumstances. For example, we may deny access if your health care provider believes it will be harmful to your health or could cause a threat to others. In these cases, we may supply the information to a third party who may release the information to you. If you are denied access to Medical Information, you may request that the denial be reviewed. Another licensed health care professional chosen by Essentia Health will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review. To make such a request, please contact the Essentia Health, Health Information Management Department.

Additional applicable state law requirements: Minnesota law requires a written and legally compliant patient consent for disclosure of Medical Information to the patient. Therefore, the proper Essentia Health form must be completed and received prior to such access being granted.

Right to Request Alternate Methods of Communication: You have the right to ask, in writing, that confidential communications about you be made in an alternative manner (such as by phone or secure messaging) or at a certain location. You do not need to state a reason. We will strive to meet all reasonable requests. Your request must state exactly how or where you wish to be contacted in the future.

To make such a request, please contact the Essentia Health Registration Department or contact the Essentia Health Privacy Officer at [email protected] or 218) 786-1172.

Right to Request Amendment: I f you feel that the Medical Information we have about you is incorrect or incomplete, you can ask us to change it. You have the right to request an amendment for as long as the information is kept by or for Essentia Health.

To request a change to your information, your request must be made in writing and submitted to the Essentia Health, Health Information Management Department. In addition, you must provide a reason that supports your request.

Essentia Health may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

• Was not created by Essentia Health, unless the person or entity that created the information is no longer available to make the amendment;
• Is not part of the medical information kept by or for Essentia Health
• Is not part of the information which you would be permitted to inspect and copy; or
• Is accurate and complete.

Right to an Accounting of Disclosures: You have the right to ask, in writing, for a list of disclosures we have made of your Medical Information. This list will not include disclosures for treatment, payment, and health care operations; disclosures that you have authorized or that have been made to you; disclosures for facility directories; disclosures for national security or intelligence purposes; disclosures to correctional institutions or law enforcement with custody of you; disclosures that took place before April 14, 2003; and certain other disclosures. Your request must state a time period, which may not be longer than six years from the date of the request, and it may not include dates before April 14, 2003. The first list requested within a 12-month period shall be provided at no charge. For more lists requested during the same 12-month period, Essentia Health may charge for the costs of providing the list.

To make such a request, please contact the Essentia Health, Health Information Management Department.

Right to Request Restrictions: You can ask Essentia Health to restrict or limit the use or disclosure of your Medical Information for treatment, payment, or health care operations. We will carefully consider all requests. However, because of the integrated nature of Essentia Health’s medical record, we are not generally able to honor most requests, nor is Essentia Health legally required to do so. If you or someone on your behalf pays for a health care item or service out-of-pocket and in full, you can request that Essentia Health not disclose information about the item or service to your health plan for payment or health care operations purposes, and we will agree to your request unless required by law to make the disclosures.

To ask for a restriction, please contact the Essentia Health Privacy Officer at [email protected] or (218) 786-1172 and they will provide the necessary form to be completed.

Key Information about this Notice
This is a revised notice for Essentia Health. The effective date of this revised notice is February 2026. Essentia Health may change its practices of how we use or disclose protected health information, or how we will implement patient rights concerning their information. We reserve the right to change the terms of this notice. We will make any revised Notice available in hard copy and display it in our locations and on our website https://www.essentiahealth.org/about/privacy-legal-notices/policy-patient/. Also, you can request the revised Notice in person or by mail.

If you have any questions or would like to discuss this Notice in more detail, please contact the Essentia Health Privacy Officer at [email protected] or (218) 786-1172.

Complaints
If you are concerned that your privacy rights may have been violated, please contact the Essentia Health Privacy Officer at [email protected] or (218) 786-1172.

You may also send a written complaint to the United States Department of Health & Human Services, Office for Civil Rights. Our Privacy Officer can provide you with information on how to file such a complaint.

Under no circumstances will we ever ask you to waive your rights under this Notice or retaliate against you in any manner for filing a complaint.

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