UCLA
Arthur Ashe Student
Health and Wellness Center

Privacy Practices

Your Right to Privacy

The Ashe Center is committed to maintaining the privacy and confidentiality of all patient information. You have the right to privacy concerning your health care. All care and counseling received at the Ashe Center will be kept strictly confidential, except as required by law. Our Notice of Privacy Practices and policy on the Disclosure of Information are provided to acquaint you with your rights as a patient.

The Medical Records unit at the Ashe Center is responsible for the maintenance, disclosure and security of all Ashe Center medical records. The privacy of your medical record is safeguarded. Information is available to any clinician, attorney or medical with your written authorization. If you would like to disclose information contained in your medical record to a third party, you must complete a written Authorization to Release Information form and submit it to Medical Records.

You can print out a copy of the Authorization to Release Information by following the link, and mail it to:

  • UCLA Ashe Medical Records
    Box 951703
    Los Angeles, CA 90095-1703

Privacy Practices Documents

U See LA Optometry & Bruin Health Pharmacy

Notice of Privacy Practices for Staff

U See LA Optometry

Notice of Privacy Practices for Students

Effective Date: September 23, 2013

Notice of Privacy Practices

UNIVERSITY OF CALIFORNIA, LOS ANGELES ARTHUR ASHE STUDENT HEALTH AND WELLNESS CENTER (UCLA Ashe Center)

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

UCLA Ashe Center

The UCLA Ashe Center (Student Health Service) is one of the health care components of the University of California. The University of California health care components consist of the UC medical centers, the UC medical groups, clinics and physician offices, the UC schools of medicine and other UC health professions schools, the student health service areas, employee health units, and the administrative and operational units that are part of the health care components of the University of California.

The University of California is a teaching and research institution and health care teaching or research may take place in connection with health care provided by the Ashe Center. All patient care is overseen and supervised by an attending physician and provided by a team of health care professionals. Residents, fellows, students and graduate students of health care professions schools may participate in examinations or procedures and in the care of patients as a part of the health care education programs of the institution.

This notice applies to information and records regarding your health care maintained at UCLA Ashe Center.

Our pledge regarding your health information

UCLA Ashe Center is committed to protecting medical, mental health and personal information about you (“Health Information”). We create a record of the care and services you receive at UCLA Ashe Center for use in your care and treatment.

This Notice tells you about the ways in which we may use and disclose Health Information about you. It also describes your rights and certain obligations we have regarding the use and disclosure of your Health Information .

We are required by law to:

  • to maintain the privacy of your Health Information
  • provide you information about our legal duties and privacy practices
  • inform you of your rights and the ways in which we may use Health Information and disclose it to other entities and persons.

How we may use and disclose health information about you

The following sections describe different ways that we may use and disclose your Health Information. Some information such as certain drug and alcohol information, HIV information and mental health information is entitled to special restrictions related to its use and disclosure. UCLA Ashe Center abides by all applicable state and federal laws related to the protection of this information. Not every use or disclosure will be listed. All of the ways we are permitted to use and disclose information, however, will fall within one of the following categories. Other uses and disclosures not described in this Notice will be made only if we have your writing authorization.

For Treatment.We may use Health Information about you to provide you with medical treatment or services. We may disclose Health Information about you to doctors, nurses, technicians, students, or other health system personnel who are involved in taking care of you in the health system. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell the hospital's food service if you have diabetes so that we can arrange for appropriate meals. We may also share Health Information about you with other UCLA Ashe Center personnel or non-UCLA Ashe Center providers, agencies or facilities in order to provide or coordinate the different things you need, such as prescriptions, lab work and x-rays. We also may disclose Health Information about you to people outside UCLA Ashe Center who may be involved in your continuing medical care after you leave UCLA Ashe Center such as other health care providers, transport companies, community agencies and family members.

For Payment.We may use and disclose Health Information about you so that the treatment and services you receive at UCLA Ashe Center or from other entities, such as an ambulance company, may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give information to your health plan about surgery you received at UCLA Ashe Center so your health plan will pay us or reimburse you for the surgery. We may also tell your health plan about a proposed treatment to determine whether your plan will pay for the treatment.

For Health Care Operations.We may use and disclose Health Information about you for our business operations. For example, your Health Information may be used to review the quality and safety of our services, or for business planning, management and administrative services. We may contact you about alternative treatment options for you or about other benefits or services we provide. We may also use and disclose your health information to an outside company that performs services for us such as accreditation, legal, computer or auditing services. These outside companies are called “business associates” and are required by law to keep your Health Information confidential. We may also disclose information to doctors, nurses, technicians, medical and other students, and other health system personnel for performance improvement and educational purposes.

Appointment Reminders.We may contact you to remind you that you have an appointment at UCLA Ashe Center.

Treatment Alternatives.We may tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Health-Related Benefits and Services.We may contact you about benefits or services that we provide.

Fundraising Activities.We may contact you to provide information about UCLA Ashe Center sponsored activities, including fundraising programs and events. We would only use contact information, such as your name, address and phone number and the dates you received treatment or services at UCLA Ashe Center. You may opt-out of receiving fundraising information by contacting us at 1- 310-825-4073 or by email at shsmail@ashe.ucla.edu.

News Gathering Activities.A member of your health care team may contact you or one of your family members to discuss whether or not you want to participate in a media or news story. News reporters often seek interviews with patients injured in accidents or experiencing particular medical conditions or procedures. For example, a reporter working on a story about a new cancer therapy may ask whether any of the patients undergoing that therapy might be willing to be interviewed.

Hospital Directory.If you are hospitalized, we may include certain limited information about you in the hospital directory. This is so your family, friends and clergy can visit you in the hospital and generally know how you are doing. This information may include your name, location in the hospital, your general condition (e.g., fair, stable, etc.) and your religious affiliation. The directory information, except for your religious affiliation, may also be released to people who ask for you by name. Your religious affiliation may be given to members of the clergy, such as ministers or rabbis, even if they don't ask for you by name. You may restrict or prohibit the use or disclosure of this information by notifying the UCLA Ashe Center Administrator of Records at UCLA Ashe Center, Box 951703, LA, CA 90095-1703.

Our disclosure of this information about you if you are hospitalized in a psychiatric hospital will be more limited.

Individuals Involved in Your Care or Payment for Your Care.We may release Health Information to anyone involved in your medical care, e.g., a friend, family member, personal representative, or any individual you identify. We may also give information to someone who helps pay for your care. We may also tell your family or friends about your general condition and that you are in the hospital.

Disaster Relief Efforts.We may disclose Health Information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.

Research.The University of California is a research institution. All research projects conducted by the University of California must be approved through a special review process to protect patient safety, welfare and confidentiality. Your Health Information may be important to further research efforts and the development of new knowledge. We may use and disclose Health Information about our patients for research purposes, subject to the confidentiality provisions of state and federal law. On occasion, researchers contact patients regarding their interest in participating in certain research studies. Enrollment in those studies can only occur after you have been informed about the study, had an opportunity to ask questions, and indicated your willingness to participate by signing a consent form. When approved through a special review process, other studies may be performed using your Health Information without requiring your consent. These studies will not affect your treatment or welfare, and your Health Information will continue to be protected. For example, a research study may involve a chart review to compare the outcomes of patients who received different types of treatment.

As Required By Law.We will disclose Health Information about you when required to do so by federal or state law.

To Prevent a Serious Threat to Health or Safety.We may use and disclose Health Information about you when necessary to prevent or lessen a serious and imminent threat to your health and safety or the health and safety of the public or another person. Any disclosure would be to someone able to help stop or reduce the threat.

Organ and Tissue Donation.If you are an organ donor, we may release Health Information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

Military and Veterans.If you are or were a member of the armed forces, we may release Health Information about you to military command authorities as authorized or required by law.

Workers' Compensation.We may use or disclose Health Information about you for Workers' Compensation or similar programs as authorized or required by law. These programs provide benefits for work-related injuries or illness.

Public Health Disclosures.We may disclose Health Information about you for public health purposes. These purposes generally include the following:

  • preventing or controlling disease (such as cancer and tuberculosis), injury or disability
  • reporting vital events such as births and deaths
  • reporting child abuse or neglect
  • reporting adverse events or surveillance related to food, medications or defects or problems with products
  • notifying persons of recalls, repairs or replacements of products they may be using
  • notifying a person who may have been exposed to a disease or may be at risk of contracting or spreading a disease or condition

Abuse and Neglect Reporting.We may disclose your Health Information to a government authority that is permitted by law to receive reports of abuse, neglect or domestic violence.

Health Oversight Activities.We may disclose Health Information to governmental, licensing, auditing, and accrediting agencies as authorized or required by law.

Lawsuits and Other Legal Proceedings.We may disclose Health Information to courts, attorneys and court employees in the course of conservatorship, writs and certain other judicial or administrative proceedings. We may also disclose Health Information about you in response to a court or administrative order, or in response to a subpoena, discovery request, warrant, or other lawful process.

Law Enforcement.If asked to do so by law enforcement, and as authorized or required by law, we may release Health information:

  • To identify or locate a suspect, fugitive, material witness, certain escapees, or missing person;
  • About a suspected victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement;
  • About a death suspected to be the result of criminal conduct;
  • About criminal conduct at UCLA Ashe Center;
  • In case of a medical emergency, to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

Coroners, Medical Examiners and Funeral Directors.In most circumstances, we may disclose Health Information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine cause of death. We may also disclose Health Information about patients of UCLA Ashe Center to funeral directors as necessary to carry out their duties.

National Security and Intelligence Activities.As authorized or required by law, we may disclose Health Information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities.

Protective Services for the President and Others.As authorized or required by law, we may disclose Health Information about you to authorized federal officials so they may conduct special investigations or provide protection to the President, other authorized persons or foreign heads of state.

Inmates.If you are an inmate of a correctional institution or under the custody of law enforcement officials, we may release Health Information about you to the correctional institution as authorized or required by law.

Psychotherapy Notes.Psychotherapy notesmeans notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual’s medical record. Psychotherapy notes have additional protections under federal law and most uses or disclosures of psychotherapy require your written authorization.

Marketing or Sale of Health Information.Most uses and disclosures of your Health Information for marketing purposes or any sale of your Health Information would require your written authorization.

OTHER USES AND DISCLOSURES OF HEALTH INFORMATION

Other uses and disclosures of Health Information not covered by this Notice will be made only with your written authorization. If you authorize us to use or disclose your Health Information, you may revoke that authorization, in writing, at any time. However, the revocation will not be effective for information that we have already used and disclosed in reliance on the authorization.

Your rights regarding health information about you

Your Health Information is the property of UCLA Ashe Center. You have the following rights, however, regarding Health Information we maintain about you:

Right to Inspect and Copy.With certain exceptions, you have the right to inspect and/or receive a copy of your Health Information. If we have the information in electronic format then you have the right to get your Health Information in electronic format if it is possible for us to do so. If not we will work with you to agree on a way for you to get the information electronically or as a paper copy.

To inspect and/or to receive a copy of your Health information, you must submit your request in writing to:

  • UCLA Ashe Center Medical Records
    Box 951703
    Los Angeles, CA 90095-1703

We may deny your request to inspect and/or to receive a copy in certain limited circumstances. If you are denied access to Health Information, in most cases, you may have the denial reviewed. Another licensed health care professional chosen by UCLA Ashe Center 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 Request an Amendment or Addendum.If you feel that Health Information we have about you is incorrect or incomplete, you may ask us to amend the information or add an addendum (addition to the record). You have the right to request an amendment or addendum for as long as the information is kept by or for UCLA Ashe Center.

Amendment. To request an amendment, your request must be made in writing and submitted to:

  • UCLA Ashe Center Administrator of Records
    Box 951703
    Los Angeles, CA 90095-1703

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 UCLA Ashe Center
  • Is not part of the Health information kept by or for UCLA Ashe Center
  • Is not part of the information which you would be permitted to inspect and copy or
  • UCLA Ashe Center believes to be accurate and complete.

Addendum. To submit an addendum, the addendum must be made in writing and submitted to:

  • UCLA Ashe Center Administrator of Records
    Box 951703
    Los Angeles, CA 90095-1703

An addendum must not be longer than 250 words per alleged incomplete or incorrect item in your record.

Right to an Accounting of Disclosures.You have the right to receive a list of certain disclosures we have made of your Health Information.

To request this accounting of disclosures, you must submit your request in writing to:

  • UCLA Ashe Center Administrator of Records
    Box 951703
    Los Angeles, CA 90095-1703

Your request must state a time period that may not be longer than the six previous years and may not include dates before April 14, 2003. You are entitled to one accounting within any 12- month period at no cost. If you request a second accounting within that 12-month period, there will be a charge for the cost of compiling the accounting. We will notify you of 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 Health Information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the Health Information we disclose about you to someone who is involved in your care or the payment for your care, such as a family member or friend. For example, you could ask that we not use or disclose information to a family member about a surgery you had.

  • UCLA Ashe Center Administrator of Records
    Box 951703
    Los Angeles, CA 90095-1703

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, only to you and your spouse. We are not required to agree to your request. If we do agree, our agreement must be in writing, and we will comply with your request unless the information is needed to provide you emergency treatment.

We are required to agree to a request not to share your information with your health plan if the following conditions are met:

  1. We are not otherwise required by lay to share the information
  2. The information would be shared with your insurance company for payment purposes;
  3. You pay the entire amount due for the health care item or service out of your own pocket or someone else pays the entire amount for you.

Right to Request Confidential Communications.You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you may ask that we contact you only at home or only by mail.

To request confidential communications, you must make your request in writing to:

  • UCLA Ashe Center Administrator of Records
    Box 951703
    Los Angeles, CA 90095-1703

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.

Copies of this Notice are available throughout the Ashe Center, on the Patient Portal, or you may obtain a copy at our website, https://www.studenthealth.ucla.edu/about/privacy-practices

CHANGES TO UCLA ARTHUR ASHE STUDENT HEALTH AND WELLNESS CENTER’S PRIVACY PRACTICES AND THIS NOTICE

We reserve the right to change UCLA Ashe Center’s privacy practices and this Notice. We reserve the right to make the revised or changed Notice effective for Health 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 at UCLA Ashe Center. The Notice will contain the effective date on the first page in the top right-hand corner. In addition, at any time you may request a copy of the current Notice in effect.

QUESTIONS OR COMPLAINTS

If you have questions about this Notice, please contact:

  • Kate Mulligan
    UCLA Ashe Center
    Box 951703
    Los Angeles, CA 90095-1703
    (310) 206-7171

If you believe your privacy rights have been violated, you may file a complaint with UCLA Ashe Center. To file a written complaint with UCLA Ashe Center, contact:

  • Kate Mulligan
    UCLA Ashe Center
    Box 951703
    Los Angeles, CA 90095-1703
    (310) 206-7171

You will not be penalized for filing a complaint.