This notice describes how medical and private information about you may be used and disclosed and how you can get this information.
Why do we ask you for this information?
To decide if you are eligible to receive our services
To improve the quality of our services
To coordinate with other service providers to meet your needs
To make reports, do research, conduct audits, and evaluate our programs
To collect money from federal, state or county government for help we give you.
To tell you apart from other people with the same or similar name
Why do we ask you for your Social Security number?
You do not have to give us your SSN. It is only used to prevent duplication in our database. Your SSN will not be shared with anyone.
Do you have to answer the questions we ask?
You do not have to give us your personal information. However, we need this information to tell if you can get help from us. Without the information, we may not be able to help you.
What information we might share and with whom?
*Private information is shared within our agency on a need-to-know basis among Evergreen staff, board members, and contracted service providers who sign our agency confidentiality statements. One example of this would be our contractual RN. Generally, we need your and/or your guardian's written permission to share your private information with anyone outside of our agency.
*MN Department Human Services, the Administration of Children and Family Services, and the Office of Economic Opportunity, and certified auditors can monitor our program’s compliance with federal and state statutes and rules. They can sample client files during monitoring visits.
*The Runaway and Homeless Act allows the U.S. Department of Health and Humans Services to collect general information on runaway, homeless youth, and youth at risk for running away. This information is stored on a secure database. Any information that would identify you, including your SSN, is removed before the data summaries are shared.
*Your county or Tribal social services may need some private information to determine if shelter stays are eligible for reimbursement. The information is kept confidential through a written agreement between Evergreen and our host county. Other counties abide by this same contract.
*The Department of Corrections may request some private information if you are here at their request.
*We may need to share private information if it is requested by courts or as a part of an investigation.
*Our staff are mandated to report if you have been mistreated, neglected or are a threat to yourself or others.
*Your caregiver has certain rights to private information regarding your health and welfare.
What privacy rights do children have?
If you are under 18, when parental consent for medical treatment is not required, information will not be shown to parents unless the health care provider believes not sharing the information would risk your health. Parents may see other information about you and let others see this information, unless you have asked that this information not be shared with your parents. You must ask for this in writing and say what information you do not want to share and why. If the agency agrees that sharing the information is not in your best interest, the information will not be shared with your parents. If the agency does not agree, the information may be shared with your parents if they ask for it.
What if you believe your privacy rights have been violated?
If you believe your privacy rights have been violated, you may send a written complaint to:
Data Practices Official; Minnesota Department of Human Services
444 Lafayette Rd.; St. Paul, MN 55155
Upon request, copies of your confidential record will be made available within 10 days not counting weekends or holidays. You have the right to get a record of some of the people or organizations with whom we have shared your information. You may challenge the accuracy of the private data given you. Make requests to: Program Director at the Evergreen Shelter Program on 7th and Mississippi Avenue or mail it to: Program Director, Evergreen Shelter Program, P.O. Box 662, Bemidji, MN 56619. If you have any questions ask the staff person who is working with you.
Please, indicate by signing that you these data privacy rights have been explained and provided for you: