St. Norbert College
St. Norbert College
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HIPAA information and release forms

The Health and Wellness Services staff provides confidential services practicing within professional ethics and laws that protect one's privacy, although there are a few exceptions. These exceptions include a court order, imminent danger to oneself or others, and child or elder abuse. Otherwise, any information disclosed from Health and Wellness Services will be released only with the individual’s written consent.

There are some exceptions, although rare; a court of law can order us to release health and counseling records and we must comply. If the staff believes there is imminent danger to your life or the life of another person, we will do what is necessary to reduce that danger, and contact someone who can assist in assuring the safety of all persons.

Notice of privacy practices
Health and Wellness records are kept separate from all other academic files to ensure that individual privacy and confidentiality are maintained. No information is released without the knowledge and written consent of the individual except for those rare instances identified. This notice describes how private health information about you may be used and disclosed by the St. Norbert College Health and Wellness Services and how you can access this information. Please review this notice carefully.

Understanding your protected health information (PHI)
When you visit the Health and Wellness Services, a record is made which consists of your private health information. Your record is the property of St. Norbert College, the information within belongs to you. Being aware of what is in your record will help you to make more informed decisions when authorizing disclosure to others. In using and disclosing your (PHI), it is our objective to follow the Wisconsin state law and the privacy act of the Federal Health Insurance Portability and Accountability Act (HIPAA). Your health record serves as:

•    A basis for planning your care and treatment.
•    A means of communication among the health care professionals who may contribute to your care.
•    A legal document describing the care you received.
•    A tool with which we can assess and continually work to improve the care given and the outcomes we achieve.

Responsibilities of Health and Wellness Services concerning your PHI
Health and Wellness Services will:

•    Maintain the privacy of your PHI as required by law and provide you with the opportunity to review our HIPAA policies.
•    Abide by the terms of this notice currently in effect. We have the right to change our notice of privacy practices and to make the new provisions effective for all protected health information that we maintain, including that obtained prior to the change. Should our information practices change, we will post new changes and provide you with a copy.
•    Notify you if we are unable to agree to a requested restriction.
•    Accommodate reasonable requests to communicate with you about your PHI by alternative means or at alternative locations.
•    Use or disclose your health information only with your authorization except as described in this notice.

Your PHI rights
You have the right to:

•    Review and obtain a paper copy of the notice of information practices upon request. You may also be informed about what is contained in your PHI. Your request to review your health or counseling record needs to be in writing and needs the approval of the director of Health and Wellness Services. PHI will be given in summary form and when  possible will include the presence of the treating provider.
•    Request and provide written authorization and permission to release information (both verbally and/or in writing) for purposes of outside treatment and health care operations.
•    Revoke your authorization in writing at any time to use, disclose or restrict health information except to the extent that action has already been taken.
•    Request a restriction on certain uses and disclosures of your PHI. The Health and Wellness Services may not be required to agree to the restriction request. Address restriction requests, in writing, to the director of Health and Wellness Services.
•    Request that we amend your health information. This request must be submitted in writing, with the reasons supporting the amendment.
•    Obtain an accounting of disclosures of your health information for purposes other than treatment and care operation and certain other activities for the last six years, but not before April 14, 2003.

Disclosures for treatment and health operations
Health and Wellness Services will use your PHI, with your consent, in the following circumstances:

Disclosure to others outside of Health and Wellness Services
With your written authorization, we will discuss (verbally and/or in writing) information that is mutually agreed upon between you and your health provider with an outside party. You may revoke a written authorization permitting a release of your PHI at any time. However, the revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Health and Wellness Services will not use or disclose your PHI without your authorization except as described below:
For health care operations
With your permission, members of Health and Wellness Services may use information in your health record to assess the performance, operations and outcome of services.
General contact
With your permission, the health and counseling providers may contact you to provide appointment reminders, information about treatment alternatives, other health-related benefits and services that may be of interest to you. You will be asked how you would like health and counseling staff to contact you, e.g. phone (with the type of information that may be conveyed) and/or letter. Health and Wellness Services does NOT use e-mail as a form of communication with students receiving services.

Health and Wellness Services will use your PHI, without your consent or authorization, in the following circumstances:

Child abuse
If the health or counseling staff have reasonable cause to suspect that a child has been, or is in danger of abuse, neglect or threatened with abuse or neglect, a report must be made to a relevant county department, child welfare agency, police or sheriff's department.
Adult and domestic abuse
If the health or counseling staff have reasonable cause to suspect that an elder person is the victim of abuse, neglect, domestic violence or other crimes, a report may be filed with the relevant county department or state official.
Serious threat to health or safety
If the health or counseling staff have reasonable cause to suspect, exercising best judgment and professional care and skill, that you may cause harm to yourself or another person, steps may be taken to notify or assist in notifying a family member, personal representative, College official(s), police and/or anyone else who may help maintain your or another's physical safety. A plan may be developed which requires an assessment for commitment proceedings.
Judicial or administrative proceedings
If you are involved in a court proceeding and a request is made for information about your diagnosis, treatment and/or mental health records, such information is privileged under state law and will NOT be released without written authorization from you or your personal or legally-appointed representative. The privilege does not apply when a third party is evaluating you or where the evaluation is court ordered. A court order may also require, without your consent, the release of health and counseling records.
As required by law for national security and law enforcement
We may disclose your health information, under certain circumstances, to military authorities. Health and Wellness Services may disclose to authorized federal officials, health information required for lawful intelligence, counterintelligence and other national security activities. Health and Wellness Services may also disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.
Law/health oversight
As required by law, we may disclose your health information for investigative purposes. For example, if the Wisconsin Department of Regulation and Licensing requests that we release records to them in order for the Medical or Psychology Examining Board to investigate a complaint against a provider, we must comply with the request.
As required by law for purposes of public health
Health and Wellness Services may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury or disability.
Consultation/office management
health care providers and therapists may consult with other practitioners to help mange and coordinate your treatment. Administrative staff (e.g. office manager/receptionist) may also have limited access to your PHI.

Business associates
There are some services Health and Wellness Services provides that may require contacts with business associates. Examples include: computer support for scheduling, note taking and scoring of diagnostic tests, reference labs, etc. When these services are contracted, we may disclose your health information to our business associates. Business associates will safeguard your information.

For additional information on HIPAA and the St. Norbert College Health and Wellness policies and procedures, visit the HIPAA documents web page.

For more information or to report a problem

If you have questions and would like additional information, please ask your clinician who will provide you with more information or help you schedule an appointment with the director of Health and Wellness Services.

If you are concerned that your privacy rights have been violated, or if you disagree with a decision Health and Wellness Services has made about access to your health information, or if you would like to make a request to amend or restrict the use or disclosure of your health information, you may discuss these issues with your health or mental health provider or you may contact the director of Health and Wellness Services.

If you believe that your privacy rights have been violated, you may also file a complaint with the Secretary of the U.S. Department of Health and Human Services. The director of Health and Wellness Services will provide you with the address for filing a complaint upon request.

Health and Wellness Services respects individual’s right to the privacy of their health information. There will be no retaliation in any way for filing a complaint with the U.S. Department of Health and Human Services or any other appropriate agency, department or person.

Health Services

Phone: (920) 403-3266
Fax: (920) 403-3099

St. Norbert College • 100 Grant Street • De Pere, WI 54115-2099 • 920-337-3181