NOTICE OF PRIVACY PRACTICES

Effective Date: April 14, 2003

The following is the Notice of Privacy Practices of every health care component at Framingham State College, as described in the Health Insurance Portability and Accountability Act of 1996 and regulations promulgated there under, commonly known as HIPAA.  For the purposes of this Notice, the health care components shall be referred to collectively as “the Health Center.”  HIPAA requires the Health Center to maintain the privacy of your personal health information and to provide you with notice of the Health Center’s legal duties and privacy policies with respect to your personal health information.

Our Pledge Regarding Medical Information

The Health Center understands that medical information about you and your health is personal.  We are committed to protecting medical information about you.  We create a record of the care and services you receive at the Health Center.  We need this record to provide you with quality care and to comply with certain legal requirements.  This notice applies to all of the records of your care generated by the Health Center, whether made by Health Center personnel or your personal doctor.  Your personal doctor may have different policies or notices regarding the doctor’s use and disclosure of your medical information created in the doctor’s office or clinic.

This notice will tell you about the ways in which the Health Center may use and disclose medical information about you.  We also describe your rights and certain obligations we have regarding the use and disclosure of medical information. 

We are required by law to:

•  make sure that medical information is kept private;

• give you this notice of our legal duties and privacy practices with respect to medical information about you;

• follow the terms of the notice that is currently in effect.

Your Personal Health Information

The Health Center collects personal health information from you through treatment, payment and related healthcare operations, the application and enrollment process, and/or healthcare providers or health plans, or through other means, as applicable.  Your personal health information that is protected by law broadly includes any information, oral, written or recorded, that is created or received by certain health care entities, including health care providers, such as physicians and hospitals, as well as, health insurance companies or plans. The law specifically protects health information that contains data, such as your name, address, social security number, and others, that could be used to identify you as the individual patient who is associated with that health information.

The 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 the 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 a legal requirement.  We must follow the privacy practices described in this notice.

How we may use or Disclosure

Your Personal Health Information

Generally, we may not use or disclose your personal health information without your permission.  Further, once your permission has been obtained, we must use or disclose your personal health information in accordance with the specific terms of that permission.  The following are the circumstances under which we are permitted by law to use or disclose your personal health information.

Uses and Disclosures Without Your Express Permission

• Treatment:  For example, a doctor may use the information in your medical record to determine which treatment option, such as a drug or surgery, best addresses your health needs.  The treatment selected will be documented in your medical record, so that other health care professionals can make informed decisions about your care.

• Payment:  In order for an insurance company to pay for your treatment, we must submit a bill that identifies you, your diagnosis, and the treatment provided to you.  As a result, we will pass such health information onto an insurer in order to help receive payment for your medical bills.

• Health Care Operations:  We may need your diagnosis, treatment, and outcome information in order to improve the quality or cost of care we deliver.  These quality and cost improvement activities may include evaluating the performance of your doctors, nurses and other health care professionals, or examining the effectiveness of the treatment provided to you when compared to patients in similar situations.

•  Appointment Reminders: Unless you object, we may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care at the Health Center.

• Treatment Alternatives: Unless you object, we may use and disclose medical information to tell you about or recommend possible treatment options or new services. 

• Health-Related Benefits and Services: Unless you object, we may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.

• To those involved with your care or payment of your care:  If people such as family members, relatives, or close personal friends are helping care for you or helping you pay your medical bills, we may release important health information about you to those people.  The information released to these people may include your location within our facility, your general condition, or death. 

You have the right to object to such disclosure, unless you are unable to function or there is an emergency.  In addition, we may release your health information to organizations authorized to handle disaster relief efforts so those who care for you can receive information about your location or health status.  We may allow you to agree or disagree orally to such release, unless there is an emergency. 

• As required or permitted by law:  Sometimes we must report some of your health information to state or federal legal authorities, such as law enforcement officials, court officials, or government agencies.  For example, we may have to report abuse, neglect, domestic violence or certain physical injuries, or to respond to a court order.

•  For public health activities:  We may be required to report your health information to authorities to help prevent or control disease, injury, or disability.  This may include using your medical record to report certain diseases, injuries, birth or death information, information of concern to the Food and Drug Administration, or information related to child abuse or neglect.  We may also have to report to your employer certain work-related illnesses and injuries so that your workplace can be monitored for safety.

• For health oversight activities:  We may disclose your health information to authorities so they can monitor, investigate, inspect, discipline or license those who work in the health care system or for government benefit programs. 

• For activities related to death:  We may disclose your health information to coroners, medical examiners and funeral directors so they can carry out their duties related to your death, such as identifying the body, determining cause of death, or in the case of funeral directors, to carry out funeral preparation activities.

• For organ, eye or tissue donation:  We may disclose your health information to people involved with obtaining, storing or transplanting organs, eyes or tissue of cadavers for donation purposes.

• For research:  Under certain circumstances, and only after a special approval process, we may use and disclose your health information to help conduct research.  Such research might try to find out whether a certain treatment is effective in curing an illness.

• To avoid a serious threat to health or safety: As required by law and standards of ethical conduct, we may release your health information to the proper authorities if we believe, in good faith, that such release is necessary to prevent or minimize a serious and approaching threat to your or the public’s health or safety.

• For military, national security, or incarceration/law enforcement custody:  If you are involved with the military, national security or intelligence activities, or you are in the custody of law enforcement officials or an inmate in a correctional institution, we may release your health information to the proper authorities so they may carry out their duties. 

• For workers’ compensation:  We may disclose your health information to the appropriate persons in order to comply with the laws related to workers’ compensation or other similar programs. 

• Lawsuits and Disputes:  If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order, subpoena or discovery request only if we have first given you notice of the order, subpoena or discovery request and an opportunity to quash it.

other uses and disclosures

Uses and disclosures for purposes other than described above require your express authorization.  For example, the Health Center must obtain your authorization before disclosing your medical information to a life insurer or to an employer, except under special circumstances such as when a disclosure to the employer is required by law. 

You have the right to revoke an authorization at any time, except to the extent that we have already relied on it in making an authorized use or disclosure.  Your revocation of an authorization must be in writing.  The Health Center hopes that if you choose to revoke an authorization, you will help us comply with your wishes by identifying the authorization you are choosing to revoke.  Ways of telling us which authorization you are revoking might include indicating who you authorized to receive information or the approximate timeframe in which you signed the authorization.

Disclosures to Business Associates

The Health Center contracts with outside companies that perform business services for us, such as billing companies, management consultants, quality assurance reviewers, accountants and attorneys.  In certain circumstances, we may need to share your medical information with a business associate so it can perform a service on your behalf.  The Health Center will limit the disclosure of your information to a business associate to the amount of information that is the minimum necessary for the company to perform services for the Health Center.  In addition, we will have a written contract in place with the business associate requiring it to protect the privacy of your medical information.

Your Health Information Rights

 You have several rights with regard to your health information.  If you wish to exercise any of the following rights, please contact:  Susanne Conley, Dean of Student Services at (508) 626-4596.  Specifically, you have the right to:

• Inspect and copy your health information:  With a few exceptions, you have the right to inspect and obtain a copy of your health information. Usually, this includes medical and billing records, but does not include psychotherapy notes or information gathered for judicial proceedings. 

To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to:

Melinda Stoops, PhD
Dean of Students
100 State Street,
Framingham, MA 01701
(508) 626-4596 

We may deny your request in very limited circumstances.  If you are denied access to medical information, you may request that the denial be reviewed.  Another licensed health care professional chosen by the Health Center 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.   

• Request to amend your health information:  If you believe your health information is incorrect, you may ask us to correct the information for as long as it is kept by the Health Center.  To request an amendment, you must make your request in writing to:

Melinda Stoops, PhD
Dean of Students
100 State Street,
Framingham, MA 01701
(508) 626-4596 

You must also give a reason as to why your health information should be changed. 

We may deny your request for an amendment if it is not in writing or if does not include a reason to support the request.  We may also deny your request if we did not create the health information that you believe is incorrect; if we disagree with you and believe your health information is correct; if the information is not part of the information which you would be permitted to inspect or copy (i.e., psychotherapy notes); or, if the information is not kept by or for the Health Center.

• Request restrictions on certain uses and disclosures:  You have the right to ask for restrictions on the medical information we use or disclose about you for treatment, payment or health care operations.  You also have the right to limit the health information provided to family or friends involved in your care or payment of medical bills.  For example, you could ask that we not use or disclose information about a particular procedure you underwent. You may also want to limit the health information provided to authorities involved with disaster relief efforts. 

To request a restriction, you must make your request in writing to:

Melinda Stoops, PhD
Dean of Students
100 State Street,
Framingham, MA 01701
(508) 626-4596 

However, we are not required to agree in all circumstances to your requested restriction.  If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment.

• As applicable, receive confidential communication of health information:  You have the right to ask that we communicate your health information to you in different ways or places.  For example, you may wish to receive information about your health status in a special, private room or through a written letter sent to a private address.  We must accommodate reasonable requests.

• Receive an accounting of disclosures of your health information:  In some limited instances, you have the right to ask for a list of the disclosures of your health information we have made during the previous six years, but the request cannot include dates before April 14, 2003.  This list must include the date of each disclosure, who received the disclosed health information, a brief description of the health information disclosed, and why the disclosure was made.  We must comply with your request for a list within 60 days, unless you agree to a 30-day extension, and we may not charge you for the list, unless you request such list more than once per year. 

We may deny your request if the disclosures made by the Health Center pertain only to:  (a) treatment, payment and health care operations; (b) individuals who request their own health information; (c) include in the facility’s directory or to those involved in the patient’s care; (d) comply with national security or intelligence purposes; (e) correctional institutions or law enforcement officials; or (e) have only disclosures made prior to April 14, 2003.

• Obtain a paper copy of this notice:  Upon your request, you may at any time receive a paper copy of this notice from any Health Center staff member, even if you earlier agreed to receive this notice electronically.  This notice is also fully accessible at http://www.framingham.edu/counseling/ .

• Complain:  If you believe your privacy rights have been violated, you may file a complaint with us and with the federal Department of Health and Human Services. To file a complaint with either entity, please contact the privacy officer listed below, who will provide you with the necessary assistance and paperwork.

Melinda Stoops, PhD
Dean of Students
100 State Street,
Framingham, MA 01701
(508) 626-4596 

The quality of your care will not be jeopardized nor will you be penalized for filing a complaint.

Changes to this Notice

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 post the revised notice (with the effective date marked clearly in the top right hand corner of the first page) at our service delivery sites and make the revised notice available to you at your request.  We will also post the revised notice at

http://www.framingham.edu/counseling/