Your Information.
Your Rights.
Our Responsibilities.

This Privacy Practices Notice describes how medical and mental health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Welcome to Student Wellness at California State University, Fullerton. The departments that comprise Student Wellness are Counseling and Psychological Services (CAPS), Disability Support Services (DSS), Health Services (HS) and Titan Well (TW) Health Promotion Services. We are staffed by a team of medical and mental health professionals to assist you in addressing your access, physical and mental health concerns. In order to provide you with the highest quality of care and services, Student Wellness utilizes an integrated treatment approach. Our multi‐disciplinary team of clinicians works collaboratively to optimize your wellness through seamless prevention and intervention. Student Wellness values the privacy of its patients and the confidentiality of the personal and health information entrusted to us. In order to protect your personal health information, we have policies and procedures regarding disclosing your Personal Health Information (PHI).


Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your health records
•  You can ask to see or get a copy of your health and claims records and other health information we have about you. Ask us how to do this.
•  We will provide a copy or a summary of your health and claims records, usually within 30 days of your request. We may charge a reasonable, cost‐based fee.

Ask us to correct your medical records
•  You can ask us to correct your health and claims records if you think they are incorrect or incomplete. Ask us how to do this.
•  We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Inspect and obtain a copy of mental health records
•  You can ask to inspect and obtain a copy of your mental health records with exceptions. Psychotherapy notes are not released and records may be withheld from inspection in compliance with state laws and instances of safety concerns.
•  We will provide a response to the request within 30 days and the request must be in writing.
•  You can request amendments; but not deletions from your record.

Restrictions of Disclosure to Insurers
•  If you pay out‐of‐pocket in full for the healthcare service, you may restrict information provided to the insurer. This request must be in writing.

Request confidential communications
•  You can ask us to contact you in a specific way (for example, home or cell phone) or to send mail to a different address.
•  We will say “yes” to all reasonable requests.

Ask us to limit what we use or share
•  You can ask us not to use or share certain health information for treatment, payment, or our operations.
•  We are not required to agree to your request, and we may say “no” if it would affect your care.

Get a list of those with whom we’ve shared information
•  You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
•  We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost‐based fee if you ask for another one within 12 months.

Get a copy of this privacy notice
•  You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you
•  If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
•  We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated
•  You can complain if you feel we have violated your rights by contacting:
        Richard Boucher, M.D.
        Chief Physician
        California State University, Fullerton
        Student Wellness
        800 N. State College Blvd.
        Fullerton, CA 92831‐6830
        (657) 278‐2800

•  You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1‐877‐696‐6775, or visiting:
•  There will be no retaliation for filing a complaint.


Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:
•  Share information with your family, close friends, or others involved in payment for your care.
•  Share information in a disaster relief situation.
•  If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
•  We may refuse a request in the case of mental health records due to additional mandates of confidentiality.

In these cases we never share your information unless you give us written permission:
•  Marketing purposes
•  Sale of your information
•  Psychotherapy notes


Our Uses and Disclosures

How do we typically use or share your health information? We typically use or share your health information in the
following ways.

Treat You
•  We can use your health information and share it with other members of your health care team (physicians, nurses, counselors, and other clinicians) who are treating you.
•  Information is shared on a strict “need to know” basis.

Run our organization
•  We can use and disclose your information to run our organization and contact you when necessary
•  We are not allowed to use genetic information to decide whether we will give you coverage and the price of that coverage.

Help with public health and safety issues
•  We can share health information about you for certain situations such as:
    - Preventing disease
    - Helping with product recalls
    - Reporting adverse reactions to medications
    - Reporting suspected abuse, neglect, or domestic violence
    - Danger to self or others
    - Risk to community

Do research
•  Aggregate data, which does not identify an individual, may be gathered and used for research.

Comply with the law
•  We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Work with a medical examiner or funeral director
 •  We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address worker’s compensation, law enforcement, and other government requests
•  We can use or share health information about you:
    - For workers’ compensation claims
    - For law enforcement purposes or with a law enforcement official, as required by law
    - With health oversight agencies for activities authorized by law
    - For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions
•  We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Bill for your services
•  We can use and share your health information to bill and receive payment if applicable.
Example: We may need to give your health plan information about a service you received here so that your health plan will reimburse you for the service. In cases of unpaid financial obligations or no show fees, we will send the charge to Student Financial Services to be processed. The bill will show the following health information: name, student ID number and date of service. No information relating to medical diagnoses, treatment/procedure, counseling session, or medications will be on this document.

 “We Never Market or Sell Personal Information.”


Our Responsibilities

•  We are required by law to maintain the privacy and security of your protected health information.
•  We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
•  We must follow the duties and privacy practices described in this notice and give you a copy of it.
•  We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information, visit:

Changes to the Terms of This Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request through the patient portal and on our website.

Effective Date of Notice: September 1, 2016