Notice of Privacy Practices (Detailed)
This detailed notice describes how information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Who will Follow This Notice?
- Any health care professional authorized to enter information into your health records
- All departments within UHS
- Any volunteer who is providing services to you while you are at UHS
- All employees, staff and other UHS personnel at all locations
Our Pledge Regarding Health Information
We understand 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 UHS. 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 UHS personnel.
To ensure confidentiality and privacy and strengthen the bonds of trust between providers and patients, we prohibit any type of secretive electronic recording or transmission of the patient visit.
To ensure confidentiality of your medical record and all communications with staff and volunteers, we prohibit the conduct of a UHS patient visit using any form of a commercial application of video chat including but not limited to Skype, Facetime, etc. It is a significant HIPAA disclosure risk to use this media and its use is not endorsed by Penn State Risk Management or PSU privacy policies.
This notice will tell you about the ways in which we 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 that identifies you is kept private;
- give you this notice of our legal duties and privacy practices with respect to medical information about you; and
- follow the terms of this notice that is currently in effect.
Understanding Your Health Record/Information
While you are a student at Penn State, UHS is one of your primary health care providers. Each time you visit UHS, a record of your visit is made. Typically, this record contains your health history, symptoms, examination and test results, diagnoses, treatment, and a plan for future care of treatment. This information, often referred to as your health or medical record, serves as:
- a basis for planning your care and treatment
- a means of communication among the many health professionals who contribute to your care
- a legal document describing the care you received
- a means by which you or a third-party payer can verify that services billed were actually provided
- a tool for educating health professionals
- a source of data for medical research
- a source of information for public health officials charged with improving the health of the nation
- a source of data for facility planning and marketing
- a tool with which we can assess and continually work to improve the care we render and the outcomes we achieve
Understanding what is in your record and how your health information is used helps you to:
- ensure its accuracy
- better understand who, what, when, where, and why others may access your health information
- make more informed decisions when authorizing disclosure to others
How We May Use and Disclose Medical Information About You
We will use your health information for treatment.
For example: Information obtained by a nurse, clinician (a physician, nurse practitioner, physician assistant) or other member of your healthcare team will be recorded in your medical record and used to determine the course of treatment that should work best for you. Your clinician will document in your record his/her expectations of the members of your healthcare team. Members of your healthcare team will then record the actions they took and their observations. In that way, the clinician will know how you are responding to treatment. A different department of UHS also may share health information about you in order to coordinate the different things you need, such as prescriptions, lab work, and x-rays. If UHS staff refer you to another clinician or hospital, information regarding your visit may be shared with these health care providers.
We will use your health information for payment.
For example: A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.
We will use your health information for regular health care operations.
For example: Members of the clinical staff, the risk or quality improvement manager, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide. We may use health information to review our treatment and services and to evaluate the performance of our staff in caring for you.
There are some services provided in our organization through contracts with business associates. Examples include reference laboratories. When these services are contracted, we may disclose your health information to our business associates so that they can perform the job we have asked them to do. We require these associates to agree that they will protect the privacy of your health information in the same manner that we do. We require these associates to agree that they will protect the privacy of your health information in the same manner that we do. Images and reports of x-ray tests performed at UHS, including those ordered by clinicians outside of UHS, are shared with the ordering clinician and are scanned into your electronic health record at UHS.
We may use and disclose health information to contact you as a reminder that you have an appointment for treatment or medical care at UHS.
We may use and disclose health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
Health-Related Benefits and Services
We may use and disclose health information to tell you about health-related benefits or services that may be of interest to you.
Individuals Involved in Your Care
In life threatening/extreme emergency situations, we may use or disclose health information to notify, or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and general condition. We may release health information about you to a friend or family member who is involved in your health care. In addition, we may disclose health information about you to an organization assisting in a disaster relief effort so that your family can be notified about your condition, status and location. You have the opportunity to agree to, prohibit or restrict the use or disclosure of health information to these individuals.
Under certain circumstances, we may use and disclose health information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who receive one medication to those who receive another, for the same condition. All research projects are subject to a special approval process. This process evaluates a proposed research project and its use of health information, trying to balance the research needs with patients' needs for privacy of their health information. Before we use or disclose health information for research, the project will have been approved through this research approval process.
As Required by Law
We will disclose health information about you when required to do so by federal, state or local law.
To Avert a Serious Threat to Health and Safety
We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent that threat.
Coroners, Medical Examiners and Funeral Directors
We may disclose health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or to determine the cause of death. We may also disclose medical information about patients of UHS to funeral directors as necessary to carry out their duties.
Public Health Risks
We may disclose health information about you for public health activities. These activities generally include the following:
- to prevent or control disease, injury or disability
- to report births and deaths
- to report child abuse or neglect
- to report reactions to medications or problems with products
- to notify people of recalls of products they may be using
- to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition
- to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law
Health Oversight Activities
We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Military and Veterans
If you are a member of the United States armed forces or foreign military personnel, we may disclose health information about you as requested by military command authorities to assure the proper execution of the military mission, if the appropriate military authority has published a notice in the Federal Register with the following information:
- appropriate military command authorities or the appropriate foreign military authority, and;
- purposes for which the protected health information may be issued or disclosed
We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers' compensation or other similar programs established by law.
Lawsuits and Disputes
In connection with a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute. We may use and disclose health information in defending or asserting a lawsuit involving your treatment at UHS.
We may disclose health information if asked to do so by a law enforcement official:
- in response to a court order, subpoena, warrant, summons or similar process
- to identify or locate a suspect, fugitive, material witness, or missing person
- about the victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement
- about a death we believe may be the result of criminal conduct
- about criminal conduct at UHS, and
- in emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.
National Security and Intelligence Activities
We may disclose health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
Protective Services of the President of the United States and Others
We may disclose health information about you to authorized federal officials so they may provide protection to the President of the United States, other authorized persons or foreign heads of state or conduct special investigations.
If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose health information about you to the correctional institution or law enforcement official. This disclosure would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; (3) for the safety and security of the correctional institutions.
We will not sell your health information, or use it for marketing of fundraising purposes without receiving written authorization.
Mount Nittany Medical Center
In order to provide the best continuity of care, the local hospital, Mount Nittany Medical Center (MNMC), may provide information to UHS regarding services that you receive there. If you would prefer that this information not be shared with UHS, please let MNMC staff know at the time of your visit.
Your Rights Regarding Medical Information About You
You have the following rights regarding health information we maintain about you:
Right to Inspect and Copy
You have the right to inspect and copy health information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes.
To inspect and copy health information that may be used to make decisions about you, you must submit your request in writing to the UHS Health Information Management (HIM) department. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.
We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to health information, you may request that the denial be reviewed. Another licensed health care professional chosen by UHS will review your request and the denial. The person conducting the review will not be the person who denied your request.
Right to Amend
If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for UHS.
To request an amendment, your request must be made in writing and submitted to the UHS HIM department. In addition, you must provide a reason that supports your request.
We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
- was not created by us, unless the person or entity that created the information is no longer available to make the amendment
- is not part of the health information kept by or for UHS
- is not part of the information which you would be permitted to inspect and copy or
- is accurate and complete
Right to an Accounting of Disclosures
You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of health information about you. This list will not include disclosures we made to you, disclosures made for the purposes of treatment, payment or our operations or those authorized by you.
To request this list or accounting of disclosures, you must submit your request in writing to the UHS Health Information Management department. Your request must state a time period, which may not be longer than six (6) years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). This first list you request within a (12) twelve-month period will be free. For additional lists, we may charge you for the cost of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
Right to Request Restrictions
You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment, or health care operations. We are not required to agree to your request. To request restrictions, you must make your request in writing to the UHS HIM department. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosure to your spouse.
You have the right to pay out of pocket for specific services, and restrict the disclosure of information pertaining to these services to third-party payers.
Right to Request Confidential Communications
You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.
To request confidential communications, you must make your request in writing to the UHS HIM department. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
Right to a Paper Copy of This Notice
You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. To obtain a paper copy of this notice you may stop by the UHS Information Desk
Changes To This Notice
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in UHS and on the website noted above. This notice will contain on the first page, in the top left-hand corner, the effective date. In addition, each time you register at UHS for treatment or health care services, we will offer you a copy of the current notice in effect.
If you believe your privacy rights have been violated, you may file a complaint with Penn State or with the Secretary of the Department of Health and Human Services. To file a complaint with Penn State, contact the Penn State Privacy Officer at 814-863-3049 or by mail at Chief Privacy Officer, Penn State University, 227 West Beaver Avenue, Suite 103, State College, PA 16801 or email firstname.lastname@example.org or HIPAA@psu.edu All complaints must be submitted in writing. You will not be penalized for filing a complaint.
Other Uses of Health Information
Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with written permission. If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.