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.”
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
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
Under limited circumstances, CCSF SHS may use or disclose
your Protected Health Information without your
Diseases that must, according to state law, be reported
to the Public Health Department (Examples include tuberculosis,
some sexually transmitted infections, and anthrax).
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.
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
If CCSF SHS is required by law to treat you, and your
health care provider has tried but is unable to get your
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.
If other applicable law prohibits or limits use or
disclosure of your PHI, CCSF SHS follows the more stringent
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
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:
To request restrictions on certain uses and disclosures
of your Protected Health Information.
To receive confidential communications of your Protected
To inspect and be provided a copy of your PHI, unless
harmful to you or to others.
To request amendment of your PHI.
To receive an accounting of disclosures of PHI.
To obtain a paper copy of this Privacy Notice.
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