Stony Brook University Student Health Service Notice of Privacy Practices

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.
STONY BROOK UNIVERSITY STUDENT HEALTH SERVICE MAY USE AND
DISCLOSE YOUR HEALTH INFORMATION FOR:
Treatment: Your health information can be used and disclosed to provide you with medical
treatment or services. We will disclose PHI about you to doctors, nurses, technicians, students
training programs or other personnel, volunteers and contracted individuals who are involved in your care. For example, your name will be on a specimen that is sent to a laboratory for testing.
Payment: The Stony Brook University Student Health Service will use and disclose your health
information to other healthcare providers to assist in the payment of your bills. Your health
information will also be used to send bills and collect payment from you, your insurance
company or other payers, such as Medicare for the care, treatment and other related services you
receive. We may inform your health insurer about a treatment your doctor has recommended to
obtain prior approval to determine whether your plan will cover the cost of the treatment.
Operations: Your health information can be used and disclosed for healthcare operational
purposes. For example, information from medical records is used to achieve and maintain
accreditation and certification.
Consent: In New York State your general consent is required for treatment and payment. Once
you sign the general consent, it will be in effect indefinitely until you withdraw/revoke your
general consent. To withdraw/revoke your general consent at any time, you must submit your
request in writing to the Student Health Service Privacy Officer. Please contact the Stony Brook
University Student Health Service Privacy Officer at (631) 632-6740 for instructions/options for
submitting your written request to withdraw/revoke your consent. Once you withdraw/revoke
your consent, the Stony Brook University Student Health Service will no longer be able to
provide you treatment, and use and disclose your health information, except to the extent that the
Stony Brook University Student Health Service has already relied on your consent. For example,
if the Stony Brook University Student Health Service provided you treatment before you
withdraw/revoke your general consent, the Stony Brook University Student Health Service may
still share your health information with your insurance company in order to obtain payment for
that treatment.
The Stony Brook University Student Health Service will obtain your authorization for the
following uses and disclosure of your health information:
Psychotherapy Notes: Any use and disclosure of psychotherapy notes other than to provide
treatment, obtain payment and perform healthcare operations requires your authorization.
Sale of PHI: The Stony Brook University Student Health Service is required to obtain your
authorization for any use and disclosure of your PHI for which the Stony Brook University
Student Health Service is receiving any form of incentive or payment.
The Stony Brook University Student Health Service will provide you with an opportunity
to agree or object to the following use and disclosure of your health information (unless you
are incapacitated, otherwise unable to reply or in the case of an emergency):
Communication With Those Involved in Your Care: The Stony Brook University Student
Health Service may use and disclose your health information to notify or assist in notifying a
family member, other relative or close personal friend about your general condition, other
information as needed to participate in the provisions of your healthcare or in the event of your
death. If you are unable or unavailable to agree or object to these communication(s), our health
professionals will use their best judgment in communicating with your family and others.
Emergencies, Disaster Relief: The Stony Brook University Student Health Service may use and
disclose your health information to a public or private entity authorized to assist in an emergency
or disaster relief effort.
Deceased Individuals: The Stony Brook University Student Health Service may use and
disclose a decedent’s health information to family members, other relative or close personal
friend who were involved in providing and/or paying for healthcare received by the decedent and
is relevant to such person’s involvement in the decedent’s healthcare; unless in doing so would
be inconsistent with any prior expressed preference made by the decedent to the Stony Brook
University Student Health Service.
The Stony Brook University Student Health Service is not required to provide you with an
opportunity to agree or object to the following use and disclosure of your health
information:
Required by Law: The Stony Brook University Student Health Service may use and disclose
your health information to comply with state and federal law(s). For example, a public health
authority that is authorized by law to collect or receive such information for the purpose of
preventing or controlling disease, injury or disability, or to an employer about an employee
relating to medical surveillance or work-related illness or injury.
Health Oversight Activities/Judicial Matters: The Stony Brook University Student Health
Service may disclose your health information for audits, investigations, inspections, licensure,
certification, the identification of individual(s) involved in a law enforcement investigation or
related activities, or to reply to a subpoena or summons.
Deceased Person/Organ Donation Information or Personal Health and Safety: The Stony
Brook University Student Health Service may disclose your health information to coroners,
medical examiners and funeral directors; organizations involved in procuring, banking or
transplanting organs and tissues; and in order to prevent or lessen a threat to the health and safety
of a person or the public.
Specialized Government Functions or Worker’s Compensation: The individual entities of the
Stony Brook University Student Health Service may disclose your information for: military and
veterans activities; national security and intelligence activities; and correctional or other law
enforcement custodial situations. We may also disclose your health information as necessary to
comply with worker’s compensation laws.
Research: The Stony Brook University Student Health Service may use and disclose your health
information for research, regardless of the source of funding, for research as approved by the
Stony Brook Committee Involving Research on Human Subjects (Institutional Review Board –
IRB) or any applicable waivers.
Marketing and Fundraising: The Stony Brook University Student Health Service may contact
you to give information about other treatment or health-related benefits and services that may be
of interest to you. Additionally, the Stony Brook University Student Health Service may contact
you to participate in marketing or fundraising activities. You have the choice of opting out of
receiving marketing and fundraising information. The Stony Brook University Student Health
Service will not sell your health information to a third party for the purposes of marketing or
fundraising or accept payment from a third party to use your health information to market a
product or service or for fundraising activities. To opt out of fundraising or marketing you may
call the Stony Brook University Student Health Service Privacy Officer at (631) 632-6740
Change of Ownership: In the event that the Stony Brook University Student Health Service is
sold or divested by the State of New York, your health information will become the property of
the new owner/entity and will be subject to their policies on health information as well as federal
and state laws.
Incidental Disclosures: The Stony Brook University Student Health Service will take
reasonable steps to protect the privacy of your health information; however, certain incidental
uses and disclosures of your health information may occur as a result of permitted uses and
disclosures that are otherwise limited in nature and cannot be reasonably prevented. For
example, discussions about your health information may be overheard by another person.
YOUR HEALTH INFORMATION RIGHTS
Receive Confidential Communications: You have the right to request that you receive your
health information through a reasonable alternative means or at an alternative location. For
example you can provide us with your cell phone number as your primary number instead of
home phone number or use a P.O. Box instead of home mailing address as your primary address.

Restrict Use/Disclosure: You have the right to submit a written request to restrict certain uses
and disclosures of your health information. Although we will attempt to accommodate your
request, the Stony Brook University Student Health Service is not required to agree or fulfill the
restriction requested; except a request to restrict disclosure of your health information to your
health plan/insurance if the disclosure is for payment or healthcare operations and pertains to a
healthcare item or service for which out of pocket payment in full has been obtained at the time
the service is provided.
Inspect and Copy: You have the right to submit a written, original signed request to inspect or
to receive a copy of your health information. The Stony Brook University Student Health
Service has policies and procedures to provide you proper access to inspect or receive a copy of
your health information. If your health information is maintained in electronic format you may
request an electronic copy of your health information instead of a paper copy. A CD containing
your requested electronic health information will be provided to you. If you request a copy of
your health information, we may charge you a reasonable fee for the copies.
Amend/Correct Information: You have the right to submit a written request to amend/correct
your health information. The Stony Brook University Student Health Service is not required to
make the requested change to your health information. A written response to your request will
be provided to you and if your request is denied the response will include the reason for the
denial and information about how you can appeal the denial.
Receive an Accounting of Disclosures: You have the right to submit a written request to receive
an accounting of disclosures of your health information made by the individual entities of the
Stony Brook University Student Health Service. We do not have to account for all disclosures of
your health information. For example, an accounting of disclosures is not required for
disclosures related to treatment, payment, healthcare operations, information that was provided
to you, information that was disclosed with your written authorization/permission and
disclosures required by state or federal law.
Detailed Explanation of Rights: You have the right to receive a paper copy of this Notice of
Privacy Practices. If you would like a more detailed explanation of these rights or if you would
like to exercise one or more of the rights, contact the Stony Brook University Student Health
Service Privacy Officer at (631) 632-6740.
Stony Brook University Student Health Service Duties:
The Stony Brook University Student Health Service will notify you, as required by law,
following a breach of your protected health information.
CHANGES TO THIS JOINT NOTICE OF PRIVACY PRACTICES
The Stony Brook University Student Health Service is required by law to comply with this
Notice of Privacy Practices. This notice can be revised and will be made available upon verbal
or written request or by contacting the Stony Brook University Student Health Service Privacy
Officer at (631) 632-6740
COMPLAINTS
Complaints about this Notice, or how the Stony Brook University Student Health Service
handles your health information, should be directed to the Stony Brook University Student
Health Service Privacy Officer at (631) 632-6740. No one will retaliate or take action against
you for filing a complaint.
If you think any of the Stony Brook University Student Health Service may have violated your
privacy rights, you may file a complaint with the Department of Health and Human Services,
Office of Civil Rights at: hhs.gov/ocr/privacy/hipaa/complaints/hipcomplaintform.pdf, or email
at OCRMail@hhs.gov or by calling (800) 368-1019.
Effective date of Original Notice: April 14, 2003
Effective date Amended Notice: September 23, 2013