The Student Health Service's staff meets regularly to review and keep current our policies. If you have any questions or concerns regarding any of our policies, please call 618/453-3311 or email firstname.lastname@example.org.
- Appointment Cancellation Policy
- Class Absence Illness/Injury Notification Policy
- Patient Rights and Responsibilities
- Patient Financial Responsibilities
- Notice of Privacy Practice
Appointments must be canceled at least TWO HOURS prior to the appointment time. Appointments not canceled accordingly and late arrivals will be assessed a $15 fee.Policy updated January 2016
- It is the policy of Student Health Services to not provide students with a written explanation of their illness or ability to attend class.
- Health providers at Student Health Services see students that are ill and require evaluation, treatment or advice. It is understood that some illnesses are self-limited and do not require medical evaluation, yet may necessitate temporary absence from class.
- Our policy asserts it is the responsibility of the student to provide verification of illness, and the faculty members responsibility to excuse an absence and determine any penalties associated with that absence.
- Explanation for Class Absence Illness/Injury Verification Form
Communicating Patient Rights and Responsibilities:
Patients’ Rights and Responsibilities is communicated to patients in writing through the Patient Rights and Responsibilities Brochure that is available in waiting areas, or electronic documents available at appointment check-in and on the Student Health Services’ website.
Patients are encouraged to express grievances, suggestions and other comments regarding one’s experiences with Student Health Services by filling out the Comment Form on-line or a printed copy located inside Student Health Services.
Most services are covered for a nominal front door fee for patients who have paid the Student Health Services Fee, although, there are additional charges for some services such as injections, routine dental care, prescriptions, over the counter pharmacy items and other services determined by the Student Health Services. Appointments related to Motor Vehicle Accident (MVA), Workers Compensation (WC) injuries/conditions and eligible patients who have not paid the Student Health Services Fee are charged the usual and customary fees. These charges may be submitted to the insurance provider on your behalf if the appropriate billing information has been provided. *
Payment is due at the time of service. Cash, check, Discover, Visa, MasterCard, American Express, and Debit Dawg are accepted. Unpaid charges will be billed to the individual or placed on the patient’s bursar account.
*Consent to Bill Insurance:
I give permission for SIU Student Health Services to bill my insurance company for covered services and to exchange information necessary to secure payment for these services. Such necessary information may include my diagnosis, service dates, types of services and other information related to services necessary to process claims.
I authorize payment of medical benefits to SIU Student Health Services.
I understand that I am responsible for any balance that my insurance company does not authorize for payment.
Acknowledgment of Financial Responsibility:
I acknowledge I have read and fully understand my financial responsibilities and have had all my questions answered. I do hereby expressly guarantee payment in full of any and all charges incurred for services rendered or to be rendered to me. Further, I agree to pay all attorney fees and court costs incurred by SHS in the collection of amounts for which I am responsible. I understand that a copy of this agreement is available upon request.
This notice describes how medical information about you may be used and disclosed and how you can gain access to this information. Please review it carefully.
The terms of this Notice of Privacy Practices apply to the Student Health Services on the SIU Carbondale Campus, operating as a clinically integrated health care arrangement. In order to provide you with health care and insurance benefits, Student Health Services collects and maintains a great deal of personal health information about you. The information in this notice will be adhered to by:
We are required by law to maintain the privacy of our patients’ personal health information and to provide patients with notice of our legal duties and privacy practices with respect to your personal health information. We are required to abide by the terms of this notice so long as it remains in effect.
Except as outlined below, we will not use or disclose your personal health information for any purpose unless you have previously signed a form authorizing the use or disclosure. Illinois law requires that we obtain consent for release of information for drug/alcohol abuse, HIV test results and/or diagnosis, and all mental health services. You have the right to revoke that authorization in writing unless we have taken action in reliance on the authorization.
We make uses and disclosures of your personal health information as necessary to provide you with treatment. For instance, doctors, nurses and other professionals involved in your care will use information in your medical record and information that you provide about your symptoms and reactions to plan a course of treatment for you that may include procedures, medications, tests, etc. We may also release your personal health information to another health care facility or professional who is not affiliated with our practice but who is or will be providing treatment to you.
We may use and disclose your personal health information to determine eligibility, coverage, cost sharing amounts, coordination of benefits, subrogation and adjudication of health benefit claims (including appeals), billing, collection and claims management activities and related health care data processing, including auditing payments, investigating and resolving payment disputes and responding to participant inquiries about payments, obtaining payment under contract for reinsurance, medical necessity reviews or reviews of appropriateness of care or justification of charges, utilization review, concurrent review and retrospective review, disclosure to consumer reporting agencies related to collection of premiums or reimbursement or to prepare a bill to send to you or the person responsible for your payment.
Health Care Operations
We may also use and disclose your personal health information as necessary and as permitted by law, for clinical improvement, professional peer review, clinical teaching, accreditation and licensing, insurance case management and care coordination, business management, data and information systems management.
Disclosure to Family and Friends
With your approval, we may, from time to time, disclose your personal health information to designated family and friends and others who are involved in your care or payment for your care in order to facilitate that person’s involvement in caring for you or paying for your care. If you are unavailable, incapacitated or facing an emergency medical situation and we determine that a limited disclosure may be in your best interest, we may share limited personal health information with individuals without your approval. We may also disclose limited personal health information to a public or private entity that is authorized to assist in disaster relief efforts in order for that entity to locate a family member or other person that may be involved in some aspect of caring for you.
To Business Associates
We may disclose medical information with written agreement to business associates who assist us with our healthcare operations, such as audits, accreditation, legal services and to technology contractors.
Appointment Reminder Services, Health Products, and Services
We may contact you to provide appointment reminders or information necessary for treatment or to advise you of a new product or service we offer or to provide general health and wellness information. You have the right to “opt-out” of receiving this service and may do so by sending your name and address together with a statement that you do not wish to receive fundraising materials or communications from us and email your statement to email@example.com.
We may use and disclose your personal health information in limited circumstances. In all cases where your specific authorization has not been obtained, your privacy will be protected by strict confidentiality requirements applied by an Institution Review Board (IRB) or privacy board which oversees the research.
We may contact you to donate for or on our behalf. You have the right to “opt-out” of receiving fundraising materials or communications and may do so by sending your name and address together with a statement that you do not wish to receive fundraising materials or communications from us and email your statement to firstname.lastname@example.org. Authorization is required for uses and disclosures of Protected Health Information (PHI) for marketing purposes that constitute a sale of PHI.
Other Uses and Disclosures
We are permitted or required by law to make certain other uses and disclosures of your personal health information without your consent or authorization, including:
Rights that You Have
You may request a copy and/or inspect much of the personal health information that we retain on your behalf. Copies will be made available to you upon request. Some fees may apply.
You may amend or correct personal health information we maintain about you, but we are not obligated to make all requested amendments. We will give each request careful consideration. If an amendment or correction you requested is made by us, we may also notify others who work with us and have copies of the uncorrected record if we believe that such notification is necessary.
You may receive an accounting of certain disclosures made by us of your personal health information after April 14, 2003. Some fees may apply.
You will be notified following any breach of unsecured PHI via certified letter with an address on file.
You may request restrictions on certain uses and disclosures of your personal health information for treatment, payment, or health care operations. We are not required to agree to your restriction request but will attempt to accommodate reasonable requests and we retain the right to terminate an agreed-to restriction if we believe such termination is appropriate. In the event of a termination by us, we will notify you of such termination. You also have the right to terminate an agreed-to restriction by emailing such written termination notice to email your statement to email@example.com. You may further restrict disclosure of your PHI to your health plan on a per visit basis by paying cash in full for services and by notifying the Student Health Services in writing of the requested restriction.
Note: All requests must be made in writing and signed by you or a representative. You may request an Access Request Form from the Records and Registration Department Supervisor at the address listed on the back of this notice.
If you believe your privacy rights have been violated, you can file a complaint with our administrative office. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services in Washington D.C. in writing within 180 days of violation of your rights. There will be no retaliation for filing a complaint. Our administrative office can provide you with the address.
Changes to this Notice
We reserve the right to change the terms of this Notice of Privacy Practices as necessary and to make the new notice effective for all personal health information maintained by us. You may receive a copy of any revised notices at our website or at the Student Health Center. If you have questions or need further assistance regarding this notice, you may email firstname.lastname@example.org. As a patient, you retain the right to a paper copy of the Notice of Privacy Practices, even if you have requested a copy by e-mail or other electronic means.
Don Howard, Privacy Officer
Phone: (618) 453-4446
Chris Woodruff, Security Officer
Phone: (618) 453-3025