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Student Health Services > Privacy and Consent

PATIENT PRIVACY
This notice describes how we may use and disclose your medical information and how you can access this information.  Please review this notice carefully.

Acknowledgement of Receipt of Notice of Privacy Practices

Athletic Training Department Consent Form

Authorization for Use or Disclosure of Information

Patient Consent

Once you sign the Lake Forest College Health Service's and/or the Athletic Training Department's consent form(s), we may use and disclose your medical information to treat you, to obtain payment, and to operate the practice.

Examples of uses and disclosures for treatment

  • If a physician or nurse practitioner at the practice refers you for a cardiac stress test and needs to call the cardiologist for results, the physician or nurse practitioner may give your name and the reason for ordering the stress test to the cardiologist's office.
  • A physician, nurse practitioner, or athletic trainer at the practice may call you to advise you of treatment alternatives.

Examples of uses and disclosures to obtain payment

  • The practice's billing office may submit a claim form that contains your name, address, social security number, diagnosis, and procedures performed in our office to your insurance company.

Examples of uses and disclosures to operate the practice

  • The practice's physician and nurse practitioner may audit (read and comment upon) your chart to improve our performance in assuring that we perform screening tests and immunizations on time.
  • The practice's staff may leave messages on your phone and ask  you to return our call.

The practice may use or disclose your protected health information only with your written authorization.  You may revoke authorization.  The practice may use and 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 disclosures include suspected abuse and infectious diseases.

You have the following rights regarding your protected health information, and the practice must act on your request within 60 days:

  • You may request restrictions on certain uses and disclosures of protected health information, but we are not required to agree to a requested restriction.
  • You may reuest that you receive confidential communication of protected health information.
  • You may request to inspect and copy your own protectged health information.
  • You may request that your information be amended.
  • You may request a paper copy of this notice.

The law requires the practice to maintain the privacy of protected health information and to provide individuals with notice of its legal duties and privacy practices.  The law requires the practice to abide by the terms of this notice and to provide individuals with notice revisions.