Privacy Notice

Interprofessional Community Health Clinic
University of Memphis Park Avenue Campus
4055 N. Park Loop, Ste. 1501, Memphis, TN 38152


Effective Date: August 23, 2021


Persons/Entities Covered By This Notice
This Notice applies to all employees, staff, faculty, and student trainees of the three programs – Applied Behavioral Analysis (ABA), Counseling Educational Psychology & Research (CEPR), and Social Work that are providing services in the Interprofessional Community Health Clinic located in the Community Health Building on the University of Memphis Park Avenue Campus.

Routine Uses and Disclosures of Your Information
We typically use or share your health information in the following ways:

  • For Treatment - We may use your health information and share it with other professionals who are treating you.
    • Example: We may share information about the treatment you receive at the Clinic with your primary care provider in order to coordinate care.
  • For Payment – We may use your health information to bill and receive payment from your health plan.
    • Example: We may have to submit information regarding your health status, diagnostic testing or evaluation, or therapy notes to your insurance company to justify the medical necessity of services or medical equipment.
  • For Health Care Operations -- We may use and share your health information to run the Clinic, improve efficiency, and contact you when necessary.
    • Example: We may use your PHI to evaluate the quality of care you receive from us, to train our students, or to make business plans for the Clinic.  We may use information about you to determine if there are other services that we might offer in the Clinic.


Other Uses and Disclosures of Your Information
We may also use or disclose your health information for the following purposes if the situation arises:

  • Health Services, Products, Treatment Alternatives and Health-Related Benefits – We may use or disclose your health information to offer other health-related products, benefits, or services that may be of interest to you.  We may recommend alternative treatments, therapies, providers, or settings of care.
  • Appointment Reminders – We may use your medical information to contact and remind you of an appointment.
  • Individuals Involved in Your Care or Payment for Your Care – We may share information with a friend or family member who helps take care of you, if you have told us it is ok to do so.  We may share information with someone who pays for your care. 
  • Personal Representative -- If you have a durable power of attorney for healthcare, please provide us with a copy of the legal document granting authority to your personal representative/medical decision-maker so that we will know your wishes.  If you have a legal guardian, please provide us with the legal documents that designate the person as your legal guardian and explain the person’s authority.
  • Minors – If the client is a minor (under 18 years old), we will follow state laws regarding when the minor may seek care without the consent of a parent or guardian and whether the record of care requires the minor’s authorization to be released to a parent or guardian.
  • Research – Being an educational institution involved in teaching and research, we may use your PHI for research purposes if the research project has been approved by an Institutional Review Board, whose role is to ensure the research has a plan to ensure appropriate protections for the data being used.  Additionally, we may use your contact information to contact you about possible participation in research projects as a research participant.
  • Fundraising – At some point in the future, the IHCH or a foundation acting on its behalf may conduct fundraising.  Your demographic data may be used to contact you for fundraising purposes.  If you do not wish to be contacted for fundraising, please contact Dezzy Moore at dmoore7@memphis.edu and asked to be excluded from any fundraising.
  • Required by Law -- We may share information about you if federal, state or local laws require it.  This includes sharing information with the U.S. Department of Health and Human Services to demonstrate we are complying with federal privacy law.
  • Public Health Risks – We may disclose your medical information (including test results) for public health purposes, such as:
    • To a public health authority to prevent or control communicable diseases, injury, or disability
    • To report child, elder or adult abuse, neglect, or domestic violence
    • To report to the FDA or other authority, reactions to medications or problems with medical products
    • To notify someone who may have been exposed to a disease or may be at risk for getting or spreading a disease or condition
  • Health Oversight Activities – We may disclose your medical information to a federal or state agency for health oversight activities, such as audits, investigations, inspections, or licensure of our medical office and the providers who treated you.
  • Law Enforcement – We may disclose limited medical information upon the request of a law enforcement official conducting an investigation.  We may also disclose medical information if needed to report a crime on our premises.
  • Serious Threat to Health or Safety – We may use and disclose your medical information when necessary to prevent a serious threat to your health and safety or to the health and safety of the public or another person.
  • Worker’s Compensation – We may disclosure your medical information for worker’s compensation or similar programs that provide benefits for work-related injuries or illness.
  • Military and Veterans – If you are a member of the U.S. or foreign armed forces or a veteran, we may release your medical information as required by military command authorities.
  • National Security – We may disclose your medical information to authorized federal officials for national security activities authorized by law.
  • Protective Services – We may disclose your medical information to authorized federal officials so they may provide protection to the President of the United States and other persons under their protection.
  • Lawsuits and Disputes – We may use or disclose your medical information to defend the clinic or a provider who treated you, if you bring a legal action against the clinic or a provider who treated you.  We may also disclose your medical information to respond to a court or governmental agency request, order, or search warrant or in response to a subpoena, discovery request, or other lawful process by another party to a legal dispute, if certain steps have been followed to make you aware of the subpoena or discovery request.

Your Rights

When it comes to your health information, you have the following rights:  

  • Right to Receive a Copy of Your Medical Information -- You can ask to see or get a copy or a summary (in paper or electronic format) of your medical record and billing information that we maintain in a designated record set.  Ask us how to do this. You can be denied the right to obtain a copy of your record only in certain, limited circumstances.  And, you may have the right to ask us to reconsider the denial, depending upon the reason for the denial.  Your rights will be explained to you if your request for access is denied.
    • We will provide a copy or a summary of your health information, usually within 10 days of your request. We may charge a reasonable, cost-based fee.
  • Right to ask us to Correct/Amend Your Medical Record -- You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.  We may deny your request, but we’ll tell you why in writing within 60 days and give you an opportunity to respond.
  • Right to Request Confidential Communications -- You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
  • Right to Request Restrictions on Using or Sharing Your Information -- You can ask us not to use or share certain health information in specific ways or with specific people or companies. We may deny your request if it would pose an undue burden on our clinic operations.
  • Right to Restrict Disclosure to Insurance -- If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information with your health insurer. We will agree to your request unless a law requires us to share that information.
  • Right to Obtain an Accounting of Disclosures (List of those with whom we’ve shared your 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, to whom we shared it, what was shared, and why.
    • We will include all the disclosures except for those for treatment, payment, and health care operations, and certain other disclosures (such as any you authorized in writing). We’ll provide one accounting per year for free, but we will charge a reasonable, cost-based fee if you ask for another one within 12 months.
  • Right to Obtain a Copy of this Privacy Notice - You can ask for a paper copy of this Privacy Notice at any time, even if you have agreed to receive an electronic version.
  • Right to File a Complaint if You Feel Your Rights Are Violated
    • You can complain if you feel we have violated your rights by contacting a clinic Privacy & Security Officer or Privacy Contact listed below.
    • 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., Room 509F HHH Bldg, Washington, D.C. 20201 or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
    • We will not retaliate against you for filing a complaint.

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 the Notice of Privacy Practices currently in effect.
  • We will provide you with a copy of the Notice of Privacy Practices upon your first visit to our office and at any other time upon request.  
  • 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. 

Changes to the Terms of this Notice
We reserve the right to change the terms of this notice.  The changes will apply to all information we have about you. The new notice will be posted in our office, with copies available upon request, and posted on our web site.

Contact Information for Privacy & Security Officers and their back-up Privacy Contacts

The following individuals can help if you have questions about how your information is used or disclosed by a particular program or if you need to file a complaint:

Applied Behavioral Analysis Program (ABA): 

Privacy & Security Officer: Dezzy Moore,  dmoore7@memphis.edu 
Privacy Contact: Thouraya Al-Nasser,  tlnasser@memphis.edu

Counseling Educational Psychology & Research (CEPR):

Privacy & Security Officer: Dezzy Moore, dmoore7@memphis.edu
Privacy Contact: Pam Cogdal, pcogdal@memphis.edu

Social Work:

Privacy & Security Officer: Dezzy Moore, dmoore7@memphis.edu
Privacy Contact: Susan Elswick, selswick@memphis.edu