Who Will Follow This Notice:
The Templeton Counseling Center (TCC) and the Chesley Health and Wellness Center (CHWC), both programs within the Division of Student Life at Illinois College have formed a collaborative arrangement with respect to the care provided by these respective programs. This notice describes the practices of the Templeton Counseling Center and the collaborative practices with Chesley Health and Wellness Center staff while providing services at Illinois College. These programs are collectively referred to as “We” or “Healthcare Members” in this notice.
Our Pledge Regarding Medical Information:
We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive at Templeton Counseling Center and/or Chesley Health and Wellness Center. Since these programs function separately for the most part, each will generate its own separate file for each individual. We need these records to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by either of these departments.
This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding use and disclosure of medical information.
We are required by law to:
• make sure that medical information that identifies you is kept private;
• give you this notice of our legal duties and privacy practices with respect to medical information about you; and
• follow the terms of the notice that is currently in effect.
How We May Use and Disclose Medical Information About You:
The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures we will provide explanation and give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.
- For Treatment: We may use medical information about you to provide you with medical treatment or services. The counselor and the nurses of the respective programs may disclose medical information about you to the Vice President for Student Affairs and other program personnel who are involved in taking care of you. For example, the counselor treating you for anxiety may speak to the Vice President of Student Affairs about the services or accommodations the college could provide to assist you in reducing your anxiety around your academic performance. Or the counselor may need to have the program secretary type a letter about your medical situation to verify your eligibility for special services or accommodations. The Templeton Counseling Center and Chesley Health and Wellness Center may also share medical information about you to coordinate the various services you need, such as medication to help reduce anxiety or depression or a diagnostic assessment to rule out psychological circumstances for physical problems. We too may disclose medical information about you to people outside the programs who may be involved in your medical care, such as family members, professors, coaches, your Resident Assistant, or others we use to provide services that are a part of your care. This disclosure of medical information to individuals outside of the programs, however, would only be done with your written consent.
- For Health Care Operations: We may use and disclose medical information about you for departmental operations. These uses and disclosures are necessary to run the department and to make sure we are providing quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff. We may also disclose information to students in professional programs for learning purposes. We may combine medical information about many student clients/patients to decide what additional services we need to offer and what services are not needed. We may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning who the specific client/patients are.
- As Required By Law: We will disclose medical information about you when required to do so by federal, state, or local law.
- If Referred by College Staff: Your participation in treatment will not be acknowledged, and personal medical information will not be discussed, with the referral source, unless you consent, in writing, that this be done.
- To Avert a Serious Threat to Health or Safety: We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat. For example, if you threatened to harm yourself, the counselor may be obligated to seek hospitalization and/or to contact family members, college personnel (including the Student of Concern Committee), or others who can help maintain your safety. If you are sent to the hospital for a mental health evaluation the Student of Concern Committee will always be notified and made aware of the outcome of this evaluation. Another example is if you threatened serious physical harm to an identifiable victim, the counselor may be required to disclose information to protect this potential victim. This may include notifying the potential victim and college personnel, contacting the police, (or) seeking your hospitalization. If any of these were to occur the Student of Concern Committee would have to be notified.
- Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
Your Rights Regarding Medical Information About You:
You have the following rights regarding medical information we maintain about you:
- Right to Inspect and Copy: You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical records but does not include psychotherapy notes, or information compiled in anticipation of a civil, criminal or administrative action or proceeding. It also does not include information obtained from third parties, (e.g. other service providers or from your relatives who may have participated in treatment), unless the third parties have consented to such disclosure.
To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to Bill Tennill, Director of Templeton Counseling for counseling records and to Judy Tonry, Director of Chesley Health and Wellness Center for health records. If you request a copy of the information, we may charge a fee for the cost of copying, mailing or other supplies associated with your request.
We may deny your request to inspect and copy in specific and very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by the Healthcare members, and the Vice President for Student Affairs will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
- Right to Amend: If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the Healthcare members.
To request an amendment, your request must be made in writing and submitted to Bill Tennill, Director of Templeton Counseling for counseling records and to Judy Tonry, Director of Chesley Health and Wellness Center for health records. In addition, you must provide a reason that supports your request.
We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
Is not part of the medical information kept by or for the Healthcare members;
Is not part of the information which you would be permitted to inspect and copy; or
Is accurate and complete.
- Right to an Accounting of Disclosures: You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of medical information about you. To request this list or accounting of disclosures, you must submit your request in writing to Bill Tennill, Director of Templeton Counseling for counseling records and to Judy Tonry, Director of Chesley Health and Wellness Center for health records. Your request must state a time period, which may not be longer than six years and may not include dates before August 15, 2008. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
- Right to Request Restrictions: You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care, like a family member or friend. For example, you could ask that we not use or disclose information about your participation in counseling.
We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
To request restrictions, you must make your request in writing to Bill Tennill, LCSW, Director of Templeton Counseling Center. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your parents.
- Right to Request Confidential Communication: You have the right to request that we communicate with you about medical matters in a certain way or a certain location. For example, you can ask that we only contact you on your cell phone or by mail.
To request confidential communications, you must make your request in writing to Bill Tennill, LCSW, Director of Templeton Counseling Center. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
- Right to a Paper Copy of This Notice: You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. To obtain a paper copy of this notice contact Bill Tennill, LCSW, Director of Templeton Counseling Center.
Changes To This Notice:
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in our main office and have a link to it on the Illinois College web site at www.ic.edu . The notice will be located in the Student Life section under Counseling Center. In addition, with each course of treatment or health care services, you may have an additional copy at your request.
If you believe our rights have been violated, you may file a complaint with the college or with the Secretary of the U.S. Department of Health and Human Services. To file a complaint with the college, contact Dean Malinda L. Carlson, Vice President of Student Affairs/Dean of Students, 217.245.3011. All complaints must be submitted in writing.
You will not be penalized for filing a complaint.
Other Uses of Medical Information:
Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.
Effective Date: May 19, 2010