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Phone: (805) 756-1211
Fax:     (805) 756-5298

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Notice of Privacy Practices

This Notice will:

  • Discuss how Health Services may use and disclose medical information about you
  • Explain your rights with respect to medical information about you
  • Describe how and where you may file a privacy-related complaint
  • Items 1-6 below describe when your medical information may be shared with others without your authorization. Read carefully.

If, at any time, you have questions about information in this Notice or about our privacy policies, p rocedures, or practices, you can contact our Privacy Officer at 805-756-2122.

  1. TREATMENT: Health Services may use and disclose medical information about you to provide, coordinate or manage your health care and related services. This may include communicating with health care providers directly involved in your treatment, such as outside specialists and Cal Poly Counseling Services. Health Services may electronically send and receive health information to contracted outside providers who are involved in your treatment, such as laboratories and radiology
    consultants. You may ask us at any time not to disclose medical information about you to persons involved in providing, coordinating or managing your care
  2. PAYMENT: Health Services may disclose medical information about you to obtain payment for health care services that you received, including the University Bursar.
  3. HEALTH CARE OPERATIONS: Health Services may use and disclose medical information about you to perform health care operations, such as quality improvement or accreditation reviews.
  4. PERSONS INVOLVED IN YOUR CARE: Health Services may disclose medical information about you to a relative, close personal friend or any other person you identify if that person is involved in your care and the information is relevant to your care or if we need to notify someone about your location or condition. If the patient is a minor, Health Services may disclose medical information about the minor to a parent, guardian, or other person responsible for the minor except in limited circumstances when such information is protected by law. You may ask us at any time not to disclose medical information about you to persons involved in your care. If the patient is a minor, Health Services may or may not be able to agree to your request.
  5. REQUIRED BY LAW: Health Services will use and disclose medical information about you whenever we are required by law to do so. For example, state law requires that we report gunshot wounds, cases of certain contagious diseases, known or suspected child/elder abuse or neglect, and domestic violence. Health Services is required to participate in the Controlled Substance Utilization Review and Evaluation System (CURES) for the electronic monitoring of the prescribing and dispensing of Schedule II and Schedule III controlled substances by all practitioners authorized to prescribe or dispense these controlled substances. Health Services must comply with those state laws and with all other applicable laws.
  6. NATIONAL PRIORITY USES AND DISCLOSURES: When permitted by law, Health Services may use or disclose medical information about you without your permission for various activities that are recognized as “national priorities.” Such disclosures would include a perceived threat to health or safety or public health activities. For more information on these types of disclosures, contact our Privacy Officer at 805-756-2122.
  7. AUTHORIZATION: Other than the uses and disclosures described above (#1-6), Health Services will not use or disclose medical information about you without your “authorization.” If you sign a written authorization allowing us to disclose medical information about you, you may later revoke (or cancel) your authorization in writing
  8. RIGHT TO HAVE MEDICAL INFORMATION AMENDED: You have the right to request that Health Services amends medical information about you that Health Services maintains in certain groups of records, if you believe that the information is either inaccurate or incomplete. You must provide a request in writing and explain why you would like information amended. Amendment Request Forms are available from our Privacy Officer.
  9. RIGHT TO AN ACCOUNTING OF DISCLOSURES HEALTH SERVICES HAS MADE: You have the right to receive an accounting (which means a detailed listing) of disclosures that Health Services has made for the previous six (6) years. The Accounting Request Forms are available from our Privacy Officer; the accounting will not include several types of disclosures, including disclosures for treatment, payment, or health care operations. It will also not include disclosures made prior to April
    14, 2003.
  10. RIGHT TO REQUEST RESTRICTIONS ON USES AND DISCLOSURES: You have the right to request that Health Services limit the use and disclosure of medical information about you for treatment, payment and health care operations. Health Services is not required to agree to your request. If Health Services does agree to your request, we must follow your restrictions (except if the information is necessary for emergency treatment). You may cancel the restrictions at any time. In
    addition, Health Services may cancel a restriction at any time.
  11. RIGHT TO REQUEST AN ALTERNATIVE METHOD OF CONTACT: You have the right to request to be contacted at a different location or by a different method. For example, you may prefer to have all written information mailed to your work address rather than to your home address. Health Services will agree to any reasonable request for alternative methods of contact. The Alternative Contact Request Forms are available from our Privacy Officer (805-756-2122). Health Services may
    change the terms of this Notice in the future. Health Services reserves the right to make changes and to make the new Notice effective for all medical information that we maintain. If Health Services makes changes to the Notice, we will post the new Notice in our waiting area and have copies of the new Notice available upon request (you may always contact our Privacy Officer at 805-756-2122 to obtain a copy of the current Notice)
  12. COMPLAINTS: If you believe that your privacy rights have been violated or if you are dissatisfied with our privacy policies or procedures, you may file a complaint either with us or with the federal government. Health Services will not take any action against you or change our treatment of you in any way if you file a complaint. You may bring your complaint to the department or you may mail it to the following address:

Privacy Officer, Health and Counseling Services
California Polytechnic State University
San Luis Obispo, California 93401

To file a complaint with the federal government, you may send your complaint to the following address:

Office for Civil Rights
U.S. Department of Health & Human Services
90 7th Street, Suite 4-100
San Francisco, CA 94103
(415) 437-8310; (415) 437-8311 (TDD)
(415) 437-8329 FAX

This form is also available as a PDF

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