Mines Policy Library

THE FOLLOWING PROVIDES IMPORTANT INFORMATION ABOUT OUR SERVICES AND YOUR RIGHTS REGARDING YOUR HEALTH RECORDS. PLEASE READ WHAT FOLLOWS CAREFULLY AND SIGN BELOW. IF YOU WOULD LIKE A COPY OF THIS INFORMATION, ASK YOUR HEALTH PROVIDER, OR FIND IT ON THE MINES WEBSITE: http://healthcenter.mines.edu/.

The Colorado School of Mines W. Lloyd Wright Wellness Center (“Wellness Center”) offers a variety of clinical and support services including medical, psychological, and psychiatric. Mines clinical services are provided by professional, credentialed physicians, nurse practitioners, psychologists, counselors, a psychiatric nurse practitioner, and other health care providers.

Eligibility for clinical and support services and referrals to the community: The Health Center provides services to currently enrolled students. Services are provided based on the urgency of presenting concerns and the availability of treatment. Should you require services that the Health Center does not provide, we will provide a referral to a treatment provider in the community, and in some instances the provider may provide support and direction as you secure these community based services. Examples of the kind of services not offered at the Health Center include specialized health care, court-mandated treatment, long-term/intensive treatment, and other forms of specialized treatment.

Emergency Services:

The Health Center is not equipped to provide emergency medical services. In the event you need emergency care that we are unable to provide, we will refer you to a higher level of care. For on campus emergencies, you can contact the Mines Public Safety dispatcher by calling 303-273-3333. Administration Office Hours: (303) 273-3333 (Monday-Friday: 8:00 a.m. – 5:00 p.m.) After hours officers will answer or you will be directed to the Golden Police Department Dispatch. Golden Dispatch: (303) 384-8045 (24/7). For off-campus emergencies, you can call 911, or go to an urgent care center or hospital emergency room.
In the event of a mental health emergency that occurs during regular business hours, come directly to the Wellness Center and inform the front desk staff that it is important that you see a counselor right away. After regular business hours, or if you have an emergency off campus, go to the nearest hospital or emergency room, or please call the following numbers:
- For medical emergencies: 911
- Local mental health crisis lines: Colorado Crisis Services at 1-844-493-8255 or Jefferson Center for Mental Health at 303-425-0300
- National Suicide Prevention Lifeline: 1-800-273-8255 or TTY 1-800-799-4889

Confidentiality and Privacy: The clinical and support services provided by the Health Center are kept confidential in a manner consistent with applicable law. The clinical providers work collaboratively to provide students with the best care possible, and this may involve sharing information about students between health and mental health staff. This information may include any clinically relevant information deemed necessary for coordinating clinical and support services between health and mental health clinicians and providers.

_____(Initial) I understand that the Wellness Center clinical staff, including medical and mental health providers, share my records for the purposes of coordinating clinical and support services within the Wellness Center.

Your health records are considered confidential. The primary laws that may be applicable to your health records are the Family Educational Rights and Privacy Act (“FERPA”) and Colorado law.

FERPA Protections: FERPA protects the privacy of your educational records, and does not allow disclosure outside of Mines without your consent, except in limited circumstances. Examples of your educational records may include billing or tracking of visits. Please see the following for additional information on FERPA, http://inside.mines.edu/FERPA.

State Law Protections: FERPA does not cover your treatment records, which are defined as records that are made or maintained by a health care professional; are used only for your medical or psychological treatment; and are available only to treatment providers. Colorado state law protects your privacy rights (“HIPAA”).

Medical Health Records: State law indicates that your medical health records are protected by privilege and are generally confidential. Subject to exceptions provided by law, Mines physicians and certified nurse practitioners, as well as members of their staff, will not disclose any medical information gathered for your treatment without your consent.

Disclosure: Mines is committed to maintaining the privacy of information that you provide to us. It is the general practice of Mines to only use or disclose protected information when you have provided written consent for such use or disclosure. You are able to revoke this consent in writing at any time. The Wellness Center clinical and medical providers will not disclose information to others about you or without your written permission except where such disclosure is required or permitted by law. The following are examples of when such disclosure may occur:

When the information is disclosed to providers of health care, health care service plans, contractors, or other health care professionals or facilities for purposes of diagnosis or treatment.
If through communication with you, Mines becomes aware that a child under 18, a developmentally disabled person, or an elderly person may be abused, exploited or neglected.
If you become a danger to others. Mines is required to take steps to protect the other person(s) and you by warning the other person(s) at risk and by reporting the danger to appropriate authorities.
If you became unable to take care of your basic needs or become a danger to yourself or others and also refuse treatment.
If Mines staff reasonably believe that disclosure will avoid or minimize an imminent danger to the health or safety of yourself or any other individual, they may disclose information (to the extent necessary) to any person, including law enforcement.
If a professional licensing board subpoenas your provider or therapist as part of its investigation, hearing or proceedings related to the discipline, issuance or denial of licensure of state licensed psychologists.
If you are involved in a court proceeding and a court orders the release of information about the professional services that the Wellness Center has provided to you or any related records.
If you are under 18-years old, your parents or legal guardian may have access to your treatment records.

In addition to the above listed exemptions to confidentiality, the Health Center clinical and medical providers are also mandated to report certain conditions per state and federal laws which affect public health and safety. Some of these include certain trauma related injuries and sexually transmitted infections. For more information about these exemptions, please contact your healthcare provider.

_____ (Initial) I have read and understand the policies related to confidentiality and its limitations outlined above.

Consent to permit testing after an occurrence of a blood or body fluid exchange: In the course of care and treatment, Wellness Center workers may be accidentally exposed to a patient’s blood or body fluids (through needle sticks, blood splatters, etc.). Communicable diseases, including the HIV virus that causes AIDS, are known to be transmitted through accidental exposures of this type. When a Health Center worker is exposed to a patient’s blood or body fluid, the patient may be required to be tested for HIV antibody and other communicable diseases in order to determine whether an actual exposure has occurred. This information is necessary so that the Wellness Center worker can receive appropriate counseling and medical treatment.

_____(Initial) I understand and agree, that in the event a Wellness Center worker is exposed to my blood or body fluids, my blood will be tested, at no cost to me, in a confidential manner, for HIV antibody, and other communicable diseases. The results of these tests will not prejudice my patient relationship by receiving services offered by the Wellness Center.

Cancellations/Late for Appointment: Except in case of emergency or illness, health center appointments should be cancelled at least 24 hours ahead of time. Check in time is 10 minutes prior to the scheduled appointment. Patients arriving past check-in time may be asked to reschedule their appointment.

_____ (Initial) I have been offered a copy of Consent to Services, Student Privacy Rights, and Disclosure. I have read the preceding information, and I understand my rights as a student-patient of the Wellness Center.

Please setup your voicemail to include your name, not just phone number. Results will only be left on your voicemail if your name is part of the recorded message.

I give permission for messages to be left on my voicemail _____Yes _____No

Phone number: _______________________________

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Student Name (Please print)

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Student Signature

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CWID (Student ID #)

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Date