Notice of Use and Disclosure of Your Medical Records

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 treatment:

• 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 treatment.
  
  

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 revisions.

Complaints
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

Patient's Rights

Your privacy rights include:

• The right to confidentiality of your records.
• The right to receive notice of MTSU Student Health Services privacy practices.
• The right to inspect and copy your medical record.
• The right to request amendment of your medical record.
• Right to request restrictions on release of your medical record.
• Right to confidential communications.

Your treatment rights include:

• The right to humane care and treatment.
• 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 services.
• The right to be informed of any research aspect of your care and the right to refuse.
• The right to have a chaperone present  during certain examinations and procedures.  
  • If you would like a chaperone present for any reason during your visit, please inform your nurse or provider.

Patient Responsibilities

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 others.
• Cancelling or rescheduling an appointment as far in advance as possible.
• Not sharing medication prescribed for you with others .