Although your health record is the physical property of the health care
practitioner or facility that compiled it, the health information in it
belongs to you. You have the right to:
- Inspect
and Copy
You have the right to inspect and obtain a copy of medical information that may be used to make decisions about your care. Usually this includes the medical record and billing records but does not include psychotherapy notes. To inspect and obtain a copy of your medical information, you must submit your request in writing. The Health Information Release Form can be downloaded. NOTE: This form is NOT automatically submitted on-line. You must print it out and deliver it to UNI Student Health Clinic either by mail or in person.
To download this form:
Option 1: PDF Format
Click here to download the Release Medical Information Form in PDF format (If you do not have Adobe Acrobat Reader, Click here to download it from the Adobe web site.)Option 2: JPG Format
We will make every effort to respond to your request within 30 days. You may be charged a fee to cover the costs of copying, mailing, or other supplies associated with your request.
The Release Medical Information Form is in JPG format. This will allow you to open the file in an Internet browser & can be printed using the "Print" button, found on both Internet Explorer and/or Netscape browsers. Click Here to view & print page 1 of the form.
- Request
Restrictions
You have the right to ask that we limit how we use and disclose your health information.
We will consider your request, but we are not legally required to accept it. If we accept your request, we will honor that request except in emergency situations. You may not limit the uses and disclosures that we are legally required or allowed to make. With this in mind, please discuss any restriction you wish to request with your physician or other health care professional. To request a restriction, notify the Contact Officer listed at the end of this notice.
- Request
Confidential Communications
You have the right to ask that we send health information to you at an alternate address. For example, you may wish to have appointment reminders and test results sent to a P.O. Box or an address different from your home address. We will accommodate reasonable requests. To make a request, please discuss it with the health care professional involved in your care.
- Amendment
You may request that we amend certain portions of your medical information, if you believe that it is incorrect or incomplete. We may require you to give a reason to support your request. We are not required to make all requested amendments, but we will give each request careful consideration. If we deny your request, we will provide you with a written explanation of the reasons and your rights.
- Accounting
of Disclosures
You have the right to obtain a list of instances in which we have disclosed your health information. Your request must state a time period not longer than six years, and your request may not include dates before April 14, 2003. The list will not include uses or disclosures made for treatment, payment, or health care operations. In addition, the list will not include uses or disclosures that you have specifically authorized in writing, such as copies of records to your attorney or to your employer. To request an accounting of disclosures, notify the Contact Officer listed at the end of this notice.
- Paper Copy
of This Notice
You have the right to request a paper copy of this notice. You may pick up a copy at the registration desk, or the notice also can be downloaded from www.uni.edu/health.
