HIPAA Notice of Privacy Practices for Protected Health Information



PLEASE REVIEW CAREFULLY Understanding Your Health Record/Information

Each time you visit a hospital, physician, or other healthcare provides, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnosis, treatment, and a plan or future care or treatment. This information, which we refer to as your health or medical record, is an essential part of the health care we provide for you.

Your health record contains personal health information, the confidentiality of which is protected under both state and federal law.

This is your Health Information Privacy Notice from the Campus Health Service. You have received this notice because you are now or in the past have been a patient at the Campus Health Center. Campus Health strongly believes in protecting the confidentiality and security of information we collect about you.

This notice describes how we protect the personal health information we have about you and how we may use and disclose this information. Personal (Protected) Health Information includes individually identifiable information which relates to your past, present or future health, treatment or payment for health care services. This notice also describes your rights with respect to the Personal Health Information and how you can exercise those rights.

We are required to provide this Notice to you by the Health Insurance Portability and Accountability Act (HIPAA) For additional information regarding our general privacy policies, please log into our web site at www.health.arizona.edu.  You may submit questions in writing to Campus Health Service, Privacy Officer, P.O. Box 210063, Tucson, Arizona 85721.

We are required by law to:

* maintain the privacy of your Personal Heath Information.

* provide you with this notice of our legal duties and privacy practices with respect to your Personal Health Information, and

* follow the terms of this notice

We protect your Personal Health Information from inappropriate use or disclosure. Our staff is required to comply with our requirements that protect the confidentiality of Personal Health Information. They may look at your Personal Health Information only when there is an appropriate reason to do so, such as to administer our services. 

We will not disclose your Personal Health Information to anyone without your written permission except for the following reasons: 

* Where Required by Law or for Public Health Activities - We disclose Personal Health Information when required by federal, state, or local law. Examples of such mandatory disclosures include notifying state or local health authorities regarding particular communicable diseases, or providing Personal Health Information to a governmental agency or regulator with health care oversight responsibilities. 

* To avert a Serious Threat to Health and Safety - We may disclose Personal Health Information to avert a serious threat to someone=s health or safety. We may also disclose Personal Health Information to federal, state or local agencies engaged in disaster relief as well as to private disaster relief or disaster assistance agencies to allow such entities to carry out their responsibilities in specific disaster situations. 

*For Law Enforcement or Specific Government Functions - We may disclose Personal Health Information in response to a request by a law enforcement official made through a court order, subpoena, warrant, summons or similar process. We may disclose Personal Health Information about you to federal officials for intelligence, counterintelligence, and other national security activities authorized by law. 

*When Requested as Part of a Regulatory or Legal Proceeding - If you or your estate are involved in a lawsuit or dispute, we may disclose Personal Health Information about you in response to a court or administrative order. We may also disclose Personal Health Information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the Personal Health Information requested. We may also disclose Personal Health Information to any government agency or regulator with whom you filed a complaint or as part of a regulatory agency examination. 

Other Uses of Personal Health Information - Other uses and disclosures of Personal Health Information not covered by this notice and permitted by the laws that apply to us will be made only with your written authorization or that of your legal representative. If we are authorized to use or disclose Personal Health Information about you, you or your legally authorized representative may revoke that authorization, in writing, at any time, except to the extent that we have taken action relying on the authorization. You should understand that we will not be able to take back any disclosures we have already made with authorization. 

Uses and Disclosures of Your Health Information

X Basis for planning your care and treatment

X Means of communicating among the many health professionals who contribute to your care

X Legal document describing the care you receive

X Means by which you or a third-party payer can verify that services billed were actually provided.

X Tool for educating health professionals

X Source of data for medical research

X Source of information for public health officials charged with improving the health of the nation.

X Tool with which we can assess and continually work to improve the care we render and the outcomes we achieve.

Uses and Disclosure that We May Make Unless You Object 

Unless you object in writing, health professionals here at Campus Health (using their best judgement) may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person=s involvement in your care or payment related to your care. 

Messages may be left on your phone regarding appointment reminders or test results, unless you object in writing. 

We expect to make other uses and disclosures of your protected health information only on the basis of specific written authorization from you. You have the right to revoke any such authorization at any time, except to the extent we have already relied on it in making an authorized use or disclosure.


The following are your various rights as a consumer under HIPAA concerning your Personal Health Information. Should you have questions about a specific right, please call or write the Campus Health Service Privacy Officer. 

*Right to Inspect and Copy your Personal Health Information: In most cases, you have the right to inspect and obtain a copy of the Personal Health Information that we maintain about you. To inspect and/or receive a copy of your Personal Health Information, you must submit in writing a request to include 1) name 2)date of birth (for identification purposes) 3) Student ID (if applicable) 4) who information is being disclosed to 4) reason for disclosure and 5) very specific instructions regarding what to release. This written request must be signed and dated. Release of Information forms may be filled out at the Medical Records window in the Campus Health Center. To receive a copy of your Personal Health Information, you may be charged a fee for the costs of copying, mailing or other supplies associated with your request. In very limited circumstances we may deny your request to inspect and obtain a copy of Personal Health Information. If we do, you may request that the denial be reviewed by the Administration Office of the Campus Health Service. 

*Right to Amend Your Personal Health Information: If you believe that your Personal Health Information is incorrect or that an important part of it is missing, you have the right to ask us to amend your Personal Health Information while it is kept by us. You must provide your request and your reason for the request in writing, and submit it to: Campus Health Service, PO Box 210063, Tucson, Arizona 85721, Atten: Privacy Officer.  We may deny your request if it is not in writing or does not include reasons that support the request. In addition, we may deny your request if you ask us to amend Personal Health Information that:

*is accurate and complete

*was not created by us, unless the person or entity that created the Personal

Health Information is no longer available to make the amendment,

*is not part of the Personal Health Information kept by or for us, or

*is not part of the Personal Health Information which you would be permitted to inspect and copy 

*Right to Request Restrictions -You have the right to request a restriction or limitation on Personal Health Information we use or disclose about you for treatment or health care operations, or that we disclose to someone who may be involved in your care, like a family member or friend. In your request, you must tell us (1) what information you want us 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, your spouse or parent). We will not agree to restrictions on Personal Health Information uses or disclosures that are legally required, or which are necessary to administer our business of health care. 

*Right to File a Complaint - If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing. You will not be penalized for filing a complaint. 


Changes to This Notice. We reserve the right to change the terms of this notice at any time. We reserve the right to make the revised or changed notice effective for Personal Health Information we already have about you as well as any Personal Health Information we receive in the future. The effective date of this notice and any revised or changed notice may be found at the bottom, left corner of the last page of this notice.

Further Information - For additional information regarding our HIPAA Medical Information Privacy Policy or our general privacy policies, please contact us at Campus Health Service, PO Box 210063, Tucson, Arizona 85721, Atten: Privacy Officer

Campus Health Service

Effective 4/14/2003