FORM 3-B PRIVACY RIGHTS STATEMENT - WRITTEN NOTICE TO CLIENT/STUDENT/FOSTER PARENTS SHERIFFS YOUTH PROGRAMS YOUR PRIVACY RIGHTS (Student/Client/Foster Parent) Information about your rights under the Minnesota Data Practices Act. The Minnesota Practices Act seeks to protect the privacy of the individuals when governmental agencies or private agencies under contract with public agencies collect data about them. The Minnesota Data Practices Act also helps people get information that is public. The information on this sheet applies to your current and future contacts with this agency, whether the contact is in person, by mail, or by phone. When we ask you to provide us with private or confidential information about yourself, you will be told: - the purpose and intended use of the data within this agency; - the legal requirements, if any, of providing information; - the consequences of providing or refusing to provide the information requested; and - the identity of other persons or agencies authorized by statute to receive the information. PURPOSES The purposes of collecting information from you are: - to determine your eligibility for services provided by this agency; - to provide effective care and treatment of your medical/social/psychological/educational problems; - to determine your ability to pay for services provided to you or to other persons for whom you are responsible; - to make referrals to other agencies or professionals to provide additional services to you - to conduct evaluations and prepare statistical reports; - to collect reimbursement from other agencies or individuals for services we give you; - to determine whether you or your children need protective services; - to evaluate and monitor our performance as an agency licensed by the State of Minnesota and accredited by the Council on Accreditation; - to develop statistics and evaluate programs. FOR FOSTER HOMES ONLY - to evaluate an application for licensure as a family foster home; - to determine if you and your home meet minimum standards for licensure; - to investigate complaints of abuse, neglect, or misconduct in a foster home; - to develop statistics and evaluate programs. LEGAL REQUIREMENTS In most cases, you are not legally required to provide the information requested. If there is such a legal requirement, you will be informed of the specific law that requires it. Generally, if you do not provide the information requested we might not be able to determine your eligibility for the services you request. In some cases, giving you services will be delayed or impossible if you refuse to provide the information. If you have applied for a license as a family foster home, your application may be denied if you refuse to provide the information. 16 - 26 MINORS If you are a minor (a child under 18 years of age), you will have the right to request that private data about you be kept from your parents. You must make this request in writing. You must explain why you wish this information to be withheld and what you expect the consequences to be if it is not withheld. If the agency agrees that withholding the information from your parents is in your best interests, it will not be shown to your parents. SHARING INFORMATION The following information you provide will be shared only under the following circumstances: - with employees of Sheriffs Youth Programs for diagn6sis, case consultation, billing and record keeping, supervision, evaluation, and administration; - with other professionals working with Sheriffs Youth Programs for case consultation, evaluation, diagnosis, and program planning; - with any individual or agency or institution or organization where you authorize sharing by signing a consent for the release of information; - you have the right to revoke you consent at any time before the information is actually shared; - with a court when the court issues a valid court order; - with the federal government when necessary to account for federal funds and programs; - with state regulatory agencies and other accrediting bodies for the purpose of monitoring and evaluating the agency's programs and services; - with appropriate law enforcement personnel, attorney, attorney general who are investigating or prosecuting a criminal or civil proceeding; - with appropriate people in an emergency; - with authorized representatives of the county human services agency who are responsible for your care and treatment; - with representatives of either law enforcement or human services when a child or a vulnerable adult is in danger; - Ombudsman Agency; - Coroner/Medical Examiner; - multi-disciplinary teams; - child or adult protective teams; - school district; - guardian, conservator, or person who has power of attorney; - social security administration. OTHER RIGHTS - You have the right to know what information Sheriffs Youth Programs are keeping about you. - You have the right to see all public and private information about you kept by Sheriffs Youth Programs. This includes the right for you to authorize other people or agencies to see it. - You have the right to have this data explained to you. - You have the right to request a copy of this information. However, you may be required to pay for the cost of that copy. - You have the right to challenge the accuracy or completeness of any private information in your records. If you want to challenge any information, write to the President/CEO of Sheriffs Youth Programs. You may also talk with the person at this agency that works with you. You will get an answer within 30 days. - You have the right to add your own explanation of anything you object to in your records. Your explanation will be attached any time that information is shared with another person or agency. - You have the right to appeal decision made by the Sheriffs Youth Programs about the accuracy or completeness of your records. To file an appeal, write to: Department of Administration Data Privacy Office State of Minnesota 50 Sherburne Avenue St Paul, MN 55155 Your appeal should include: - your name, address, and telephone number; - the name of the Commissioner of Human Services; - the name of this agency; - a description of the nature of the dispute and a description of the data in question. You must file this appeal within 60 days of the action being appealed. I have read this explanation of my privacy rights and I understand the purposes and consequences of giving the information and who is authorized to see it. SIGNED: DATE: (client/student - data subject) SIGNED: DATE: (parent/legal guardian/personal representative) If signed by a personal representative, state relationship and authority to do so: (relationship) SIGNED: DATE: If you would like a copy of this information, it will be provided for you at your request.