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Our Practice is dedicated to maintaining the privacy of your individually identifiable health information (IIHI). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We are also required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our Practice concerning your IIHI. By federal and state law, we must follow the terms of the Notice of Privacy Practices that we have in effect at the time.

We realize that these laws are complicated, but we must provide you with the following important information:

How we may use and disclose your IIHI

• Your privacy rights in your IIHI
• Our obligations concerning the use and disclosure of your IIHI

The terms of this notice apply to all records containing your IIHI that are created or retained by our Practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that our Practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our Practice will post a copy of our current Notice in our offices in a visible location at all times, and you may request a copy of our most current Notice at any time.

If you have questions about this notice, please contact ����������� Health and Wellness Center at 610-526-7360.

The following categories describe the different ways in which we may use and disclose your IIHI.

•  Treatment. Our Practice may use your IIHI to treat you. For example, we may ask you to have laboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. We might use your IIHI in order to write a prescription for you, or we might disclose your IIHI to a pharmacy when we order a prescription for you. Many of the people who work for our Practice–including, but not limited to, our doctors and nurses–may use or disclose your IIHI in order to treat you or to assist others in your treatment. Finally, we may also disclose your IIHI to other health care providers for purposes related to your treatment.
•  Payment. Our Practice may use and disclose your IIHI in order to bill and collect payment for the services and items you may receive from us. For example, we may contact the College health plan insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide the insurer with details regarding your treatment to determine if the insurer will cover, or pay for, your treatment. Also, we may use your IIHI to bill you directly for services and items. We may disclose your IIHI to other health care providers and entities to assist in their billing and collection efforts. We may also send your name and Health and Wellness Center charges to the Bursar to bill for services not paid for at the time of service.
•  Health Care Operations. Our Practice may use and disclose your IIHI to operate the Health and Wellness Center. As examples of the ways in which we may use and disclose your information for our operations, our Practice may use your IIHI to evaluate the quality of care you received from us, or to conduct cost-management and business planning activities for our Practice. We may disclose your IIHI to other health care providers and entities to assist in their health care operations.
•  Appointment Reminders. Our Practice may use and disclose your IIHI to contact you and remind you of an appointment.
•  Health-Related Benefits and Services. Our Practice may use and disclose your IIHI to inform you of health-related benefits or services that may be of interest to you.
•  Disclosures Required By Law. Our Practice will use and disclose your IIHI when we are required to do so by federal, state or local law.

The following categories describe unique scenarios in which we may use or disclose your identifiable health information.

•  Public Health Risks. Our Practice may disclose your IIHI to public health authorities that are authorized by law to collect information for the purpose of:
  •  maintaining vital records, such as births and deaths
  • reporting child abuse or neglect
  • preventing or controlling disease, injury or disability
  • notifying a person regarding potential exposure to a communicable disease
  • notifying a person regarding a potential risk for spreading or contracting a disease or condition
  • reporting reactions to drugs or problems with products or devices
  • notifying individuals if a product or device they may be using has been recalled
  • notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information
  • notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance
•  Health Oversight Activities. Our Practice may disclose your IIHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.
•  Lawsuits and Similar Proceedings. Our Practice may use and disclose your IIHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your IIHI in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.
•  Law Enforcement. We may release IIHI if asked to do so by a law enforcement official:
  •  Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement
  • Concerning a death we believe has resulted from criminal conduct
  • Regarding criminal conduct at our offices
  • In response to a warrant, summons, court order, subpoena or similar legal process
  • To identify/locate a suspect, material witness, fugitive or missing person
  • In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator)
•  Deceased Patients. Our Practice may release IIHI to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we also may release information in order for funeral directors to perform their jobs.
•  Research. Our Practice may use and disclose your IIHI for research purposes in certain limited circumstances. We will obtain your written authorization to use your IIHI for research purposes except when an Internal Review board or Privacy Board has determined that the waiver of your authorization satisfies the following: (i) the use or disclosure involves no more than a minimal risk to your privacy based on the following: (A) an adequate plan to protect the identifiers from improper use and disclosure; (B) an adequate plan to destroy the identifiers at the earliest opportunity consistent with the research (unless there is a health or research justification for retaining the identifiers or such retention is otherwise required by law); and (C) adequate written assurances that the PHI will not be re-used or disclosed to any other person or entity (except as required by law) for authorized oversight of the research study, or for other research for which the use or disclosure would otherwise be permitted; (ii) the research could not practicably be conducted without the waiver; and (iii) the research could not practicably be conducted without access to and use of the PHI.
•  Serious Threats to Health or Safety. Our Practice may use and disclose your IIHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public.
•  Military. Our Practice may disclose your IIHI if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities with your authorization.
•  National Security. Our Practice may disclose your IIHI to federal officials for intelligence and national security activities authorized by law. We also may disclose your IIHI to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.
•  Inmates. Our Practice may disclose your IIHI to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the safety and security of the institution, and/or (c) to protect your health and safety or the health and safety of other individuals.
•  Workers’ Compensation. Our Practice may release your IIHI for workers’ compensation and similar programs.
• Mandated Reporting of Child Abuse. Health care workers and mental health professionals are mandated reporters and by Pennsylvania state law are required to report suspected child abuse.

You have the following rights regarding the IIHI that we maintain about you.

• Confidential Communications. You have the right to request that our Practice communicate with you about your health and related issues in a particular manner or a certain location. Unless otherwise specified, our communication is usually by phone or campus mail to your on-campus phone or mailbox. When school is not in session or if you do not live on campus, we communicate by phone or mail to your home address we have on record. If this is not acceptable to you, you must make a written request to the ����������� Health and Wellness Center specifying requested method of contact. Our Practice will try to accommodate reasonable requests. You do not need to give a reason for your request. We do not provide confidential information over email without your permission.
• Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your IIHI for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your IIHI to only certain individuals involved in your care or the payment for your care, such as family members or friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your IIHI, you must make your request in writing to Medical Director, ����������� Health and Wellness Center, 610-526-7360. Your request must describe in a clear and concise fashion:
  •  the information you wish restricted;
  • whether you are requesting to limit our Practice’s use, disclosure or both; and
  • to whom you want the limits to apply.
• Inspection and Copies. You have the right to inspect and obtain a copy of the IIHI that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to Medical Director, ����������� Health and Wellness Center, 610-526-7360, in order to inspect and/or obtain a copy of your IIHI. Our Practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Our Practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed healthcare professional chosen by us will conduct reviews.
• Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our Practice. To request an amendment, your request must be made in writing and submitted to Medical Director, ����������� Health and Wellness Center, 610-526-7360. You must provide us with a reason that supports your request for amendment. Our Practice will deny your request if you fail to submit your request (and the reason for your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the IIHI kept by or for the Practice; (c) not part of the IIHI which you would be permitted to inspect and copy; or (d) not created by our Practice, unless the individual or entity that created the information is not available to amend the information.
•  Accounting of Disclosures. All of our patients have the right to request an “accounting of disclosures.” An “accounting of disclosures” is a list of certain non-routine disclosures our Practice has made of your IIHI for non-treatment, non-payment or non-operations purposes. Use of your IIHI as part of the routine patient care in our Practice is not required to be documented. For example, the doctor sharing information with the nurse, or the billing department using your information to file your insurance claim. In order to obtain an accounting of disclosures, you must submit your request in writing to Office Manager, ����������� Health and Wellness Center, 610-526-7360. All requests for an “accounting of disclosures” must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003. The first list you request within a 12-month period is free of charge, but our Practice may charge you for additional lists within the same 12-month period. Our Practice will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.
• Right to Obtain a Paper Copy of This Notice. You are entitled to receive a paper copy of our Notice of Privacy Practices. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact Office Manager, ����������� Health and Wellness Center,610-526-7360.
•  Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with our Practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our Practice, contact Medical Director, ����������� Health and Wellness Center, 610-526-7360. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
• Right to Provide an Authorization for Other Uses and Disclosures. Our Practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. For example, with your written permission, we will disclose information to your parents or your dean. Any authorization you provide to us regarding the use and disclosure of your IIHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your IIHI for the reasons described in the authorization. Please note, we are required to retain records of your care.

����������� Patient Rights and Responsibilities

You have the right...

1. To receive engaged, respectful care.

2. To receive an explanation of your diagnosis, treatment, and prognosis in terms you can understand.

3. To ask questions if you do not understand anything explained to you about your care.

4. To receive the necessary information to make decisions about your care.

5. To give your informed consent before any diagnostic or therapeutic procedure is performed.

6. To refuse treatment, except as prohibited by law, and to be informed of the consequences of making this decision.

7. To expect that your confidentiality will be respected by all staff at the Health and Wellness Center.

8. To expect that your health care records will be kept confidential and will be released only with your written consent, or in cases of medical emergencies, or in response to court-ordered subpoenas (confidentiality can be violated if the individual poses a significant threat of harm to self or others).

9. To know the names and positions of people involved in your care by official name tag and / or personal introduction.

10. To receive a full explanation of any research or experimental procedure proposed for treatment and the full opportunity to give your consent before any procedure begins.

11. To obtain another medical or clinical opinion, either with another ����������� staff member, or an outside provider.

12. To access your health care records as long as they remain available to the College.

13. To voice grievances regarding treatment or care, to be directed to the Director of Health Services or Director of Counseling Services.

You are responsible...

1. For providing accurate and complete information about your past health history and present symptoms/illness.

2. For asking questions if you do not understand the explanation of your diagnosis, treatment, prognosis or any instructions.

3. For providing the necessary personal information to complete your file.

4. For keeping appointments unless you notify the office with 24 hours' notice when you are unable to do so.

5. For following the recommended treatment plan or making known your disagreement with the plan.

6. For any charges billed to you, or for asking for explanation of any charges you do not understand.