DAVISON HEALTH CENTER
NOTICE OF PRIVACY PRACTICES
This notice describes how your medical information may be used and disclosed and how you can access this information. Please review it carefully.
Davison Health Center must maintain the privacy of your personal health information and give you this notice that describes our legal duties and privacy practices concerning your personal health information. In general, when we release your health information, we must release only the information we need to achieve the purpose of use or disclosure. However, all of your personal health information will be available for release to you, to a provider regarding your treatment, or due to legal requirement. We must follow the privacy practices described in this notice.
However, we reserve the right to change the privacy practices described in this notice, in accordance with the law. Changes to our privacy practices would apply to all health information we maintain. If we change our privacy practices, we will give you a revised copy of the notice by access to our website, www.wesleyan.edu/healthservices or by calling the office at 860-685-2470 and requesting a revised copy be sent to you, or receiving a copy at the time of your next appointment.
I. Uses and Disclosures of Protected Health Information
Uses and Disclosures of Protected Health Information Based Upon Your Written Consent
Upon entry to the University, you have signed a consent form to authorize Davison Health Center to provide medical treatment if you request it. Once you have signed our consent form, we can use your health information for the following purposes: Please note that if you refuse to provide consent to us, we may refuse to treat you.
Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes coordination or management of your health care with a person or entity which has already obtained your permission to have access to your protected health information.
For example, we would disclose protected health information, with your permission, to another health care provider or sports trainer who may be treating you, to ensure that they have the necessary information to diagnose and treat you.
In addition, we may disclose your protected health information from time to time to another physician or health care provider (e.g. specialist or laboratory), who, at the request of your provider, becomes involved in your healthcare by providing assistance with your diagnosis or treatment to your health care provider..
Payment: Appointments and visits to Davison Health Center are covered by your regular tuition payments. You do not have to pay extra for general visits. However, certain services provided by the Health Center, such as laboratory testing and prescription medications, may be charged to your student account with your permission. Bills that are submitted to the Student Accounts Office will not have specific or protected health information included. The Student Account Office will note on your account that you were charged for a "Health Service Fee" with a specific amount.
Also, if you are referred for services outside of the Health Center for a problem diagnosed at the Health Center, we may release to your insurance company, with your permission, relevant protected health information to assist them in determining your eligibility for coverage and benefits outside of the Health Center and reviewing services provided to you outside of the Health Center for medical necessity.
Healthcare Operations: We may use or disclose, as needed, your protected health information in the administrative activities of Davison Health Center. These activities include, but are not limited to: Quality Assurance review activities; Employee review activities; Training of medical residents and nursing students; Licensing of the Health Center and Staff.
For example, we may disclose your protected health information to medical residents and nursing students who may see you in the office while doing a training rotation here. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign in. We may also call you by name in the waiting room. We may use or disclose your protected health information, as necessary, to contact you to remind you of an appointment.
Uses and Disclosures of Protected Health Information Based Upon Your Written Authorization
Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization in writing, except to the extent that the Health Center has already sent out the requested information.
We may use and disclose your protected health information in the following instances. You have the right to agree or object to the use and disclosure of all or part of your protected health information. If you are not able to agree or object to the use or disclosure of protected health information, then your physician, in his/her professional judgment, will determine whether the disclosure is in your best interest. In this case, only the health information that is relevant to your current health problem will be discussed.
A. Others Involved In Your Healthcare: Unless you object, we may disclose to a member of your family or a close friend or any other person you identify, your protected health information that directly relates to their involvement in your healthcare. If you are unable to agree or object to such a disclosure, we may disclose the information as necessary if we determine that it is in your best interest, based on our professional judgment, to use and disclose your protected health information to notify or assist in notifying a family member, personal friend, or any other person that is responsible for your care, of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family and other individuals involved in your healthcare.
B. Emergencies: We may use or disclose your protected health information in an emergency treatment. If this happens, your health care provider shall try to obtain your consent as soon as reasonably practicable after the treatment. If your physician or another practitioner in the Health Center is required by law to treat you, and they attempted to obtain your consent but are unable to do so, they may still use your protected health information to treat you.
C. Communication Barriers: We may use or disclose your protected health information if your physician or another practitioner in the Health Center attempts to obtain consent from you but is unable to do so due to substantial language barriers and the practitioner determines, using professional judgment, that you intend to consent to treatment under the circumstances.
Other Permitted and Required Uses and Disclosures That May Be Made Without Your Consent or Opportunity to Object.
We may use or disclose your protected health information in the following situations without your consent or authorization. These situations include:
Required By Law: We may use or disclose your protected health information to the extent that the use is required by law. The use or disclosure will be made in compliance with the law, and will be limited to the requirements of the law. For example, we may have to report abuse, neglect, domestic violence, or certain physical injuries, or respond to a court order. You will be notified, as required by law, of any such uses or disclosures.
B. Public Health: We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability. We may also disclose your protected health information, as directed by the public health authority, to a foreign government agency that is collaborating with the public health authority.
C. Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading that disease or condition.
D. Health Oversight: We may disclose your protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information may include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.
E. Food and Drug Administration: We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations; to track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance as required.
F. Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful proceeding.
G. Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurred on the premises of the practice, and (6) medical emergency (not on the practice premises) where it is likely that a crime has occurred.
H. Coroners, Funeral Directors and Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining the cause of death, or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaver organ, eye and tissue donations.
I. Research: We may disclose your protected health information 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. For example, such research might help determine whether a certain treatment is effective in curing an illness.
J. Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health and safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.
K. Military Activity and National Security: When the appropriate conditions apply, we may use or disclose the protected health information of individuals who are Armed Forces personnel (1) for the activities deemed necessary by military command authorities; (2) for the purpose of a determination of eligibility for benefits by the Department of Veteran’s Administration, or (3) to a foreign military authority under which you serve as a member. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including the provision of protective services to the President or others legally authorized.
L. Worker’s Compensation: We may use or disclose your protected health information, as authorized, to comply with worker’s compensation laws and other similar legally established programs.
M. Inmates: We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you.
N. Required Uses and Disclosures: Under the law, we must make disclosures to you when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et. seq.
II. Your Rights
Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights:
A. You have the right to inspect and obtain a copy of your protected health information. This means you may obtain a copy of protected health information about you that is contained in a designated record set for as long as we maintain the protected health information. A "designated record set" contains medical and billing records and other records that your physician and the practice uses for making decisions about you. Under federal law, however, you may not inspect or copy the following records: Psychotherapy notes, information compiled in reasonable anticipation of , or use in, a civil, criminal or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have the right to have this decision reviewed. Please contact our Privacy Contact, listed at the end of this notice, if you have questions about access to your medical record.
B. You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment, or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care, or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want this restriction of access to apply.
Your physician is not required to agree to a restriction that you may request. If the physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. If your physician does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your physician. You may request a restriction by discussing it with your physician, and then requesting the specific restriction in writing.
C. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled, or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Contact, listed below.
D. You may have the right to have your physician amend your protected health information. This means you may request an amendment of protected health information about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for an amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Contact listed below if you have any questions about amending your medical record.
E. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for the purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made, to family members or friends involved in your care, or for notification purposes. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003.
The right to receive this information is subject to certain exceptions, restrictions and limitations.
F. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.
III. Complaints
You may complain to us or to the Secretary of Health and Human Services if you believe we have violated your privacy rights. You may file a complaint with us by notifying our Privacy Contact of your complaint. We will not retaliate against you for filing a complaint.
You may contact our Privacy Contact, Joyce Walter at 860-685-2470, or Davison Health Service, 327 High Street, Middletown, CT 06459, for further information about the complaint process or any other questions you have regarding this notice.
This notice is published and becomes effective on April 14, 2003.
3/03; revised 3/08; 11/18
Davison Health Center
327 High Street
Middletown, CT 06459
(860)685-2470
RECEIPT OF PRIVACY NOTICE
I, _____________________________________, have received a copy of the Davison Health Center Notice of Privacy Practices.
_______________________________ ____________________
Signature Date
_______________________________ ____________________
Witness Date
Office Use Only:
ÿ Notice sent via mail per student request. Date: ________ Witness: _________________ÿ Notice sent to first-year student with required Health Center material.
3/03