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“This notice describes how medical information about you may be used and disclosed and how you can get access to this information.  Please review it carefully.”

 What is “Protected Health Information”?

All the information regarding your health care and related information at City College of San Francisco Student Health Services (CCSF SHS) given by you or information provided to CCSF SHS at your request by other providers, and health care billing information.   Generally, it is the information in your medical record.

CCSF SHS is required by law to maintain the privacy of all Protected Health Information (PHI), to provide you with notice of our legal duties and practices, and to abide by the terms of this Notice of Privacy.  CCSF SHS reserves the right to change the terms of this Privacy Notice and will provide clients with a copy of the revised notice.

A.      Protected Health Information (PHI) is a record of the health care you receive, including billing information.  For example, an X ray may be done to diagnose your problem, and your health care provider and a radiologist may then view that X ray.  Your health care provider may then direct the nurse to give you medicine for your problem.  Your bill for this care may be sent to your insurance company for payment.

B.      Under limited circumstances, CCSF SHS may use or disclose your Protected Health Information without your consent.  These include:

1.      Diseases that must, according to state law, be reported to the Public Health Department  (Examples include tuberculosis, some sexually transmitted infections, and anthrax).

2.      Emergency situations in which you are unable to give consent, and your health care provider attempts to get consent as soon as IT is reasonable after delivery of care.

3.      Your health care provider cannot get consent due to substantial barriers in communication, and the health care provider determines that your consent is inferred from the circumstances.

4.      If CCSF SHS is required by law to treat you, and your health care provider has tried but is unable to get your consent.

5.      Review by Department of Health Services (DHS) for internal quality assessment, or by an accrediting body such as the Association for Accreditation of Ambulatory Health Care.

C.     If other applicable law prohibits or limits use or disclosure of your PHI, CCSF SHS follows the more stringent law.

D.     Any use or disclosure other than those described above is done only after you give your consent.  You may cancel your consent at any time by notifying CCSF SHS in writing.

E.      They can disclose PHI disclosed at your request by CCSF SHS to another health care provider without the knowledge of CCSF SHS. You have the right:

Ø       To request restrictions on certain uses and disclosures of your Protected Health Information.

Ø       To receive confidential communications of your Protected Health Information.

Ø       To inspect and be provided a copy of your PHI, unless harmful to you or to others.

Ø       To request amendment of your PHI.

Ø       To receive an accounting of disclosures of PHI.

Ø       To obtain a paper copy of this Privacy Notice.

Ø       To complain to CCSF SHS Clinic Director, Vice Chancellor of Student Development, and to the US Health and Human Services Secretary, if you believe your privacy rights have been violated.

If you wish to file a complaint, you may contact the Clinic Director at (415) 239-3110.  There will be no retaliation of any kind against you by City College of San Francisco for filing such a complaint.

This Privacy notice is in effect as of 4/14/2003

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