Notice of Use and Disclosure of Your
This notice describes how we may use and
disclose your medical information and how you can access this
information. Please review this notice carefully.
Examples of uses and disclosures for
If a nurse practitioner, physician's
assistant or physician (a healthcare provider) in this clinic
refers you for an x-ray and needs to call the radiologist for
results, the provider may give your name and the reason for
ordering the x-ray to the radiologist's office.
A provider from this clinic may call you to
advise you of treatment alternatives.
A provider from this clinic may release
your name, address, social security number, diagnoses and
procedures performed in this clinic to an outside laboratory so
that your insurance company can be billed for services provided
by the laboratory.
The providers may read and comment upon
your chart to track and improve our practices and your
The clinic may use or disclose your protected
health information only with your written authorization. You may
revoke that authorization.
The clinic may use or disclose protected
health information about you for other purposes, and without your
consent, if the law requires us to disclose information to
government authorities. Examples of such use include suspected
abuse and sexually transmitted diseases.
The law requires the clinic to maintain the
privacy of protected health information and to provide
individuals with notice of its legal duties and these privacy
practices. The law requires the clinic to abide by the terms of
this notice and to provide individuals with notice
You may complain to the clinic or to the U.S. Department of Heath
and Human Services if you believe your privacy rights have been
violated. To file a complaint with the clinic please write: Rick
Chapman, Director of Student Health Services. No one will
retaliate against you for filing a complaint.
Effective Date: August 1, 2002
Your privacy rights include:
The right to confidentiality of your
The right to receive notice of MTSU Student
Health Services privacy practices.
The right to inspect and copy your medical
The right to request amendment of your
Right to request restrictions on release of
your medical record.
Right to confidential
Your treatment rights include:
The right to humane care and
The right to accurate information.
The right to a second opinion regarding
diagnosis and treatment.
The right to participate in decisions
regarding your health and treatment.
The right to know who is counseling, caring
for or treating you.
The right to information regarding the
scope and availability of services.
The right to information regarding fees for
The right to be informed of any research
aspect of your care and the right to refuse.
Your responsibilities include:
Providing full information about your
illness or problem.
Asking sufficient questions to ensure you
have appropriate understanding of your illness and the
provider's recommended treatment.
Showing courtesy and respect to health
personnel and to other patient's.
Not lending your personal identification to
Cancelling or rescheduling an appointment
as far in advance as possible.
Not sharing medication prescribed for you