Student Accommodation Request

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Student Information

*Please note if you are already registered with Student Accessibility, complete a Semester Request to activate accommodations for this current term

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Please use your full email address (sample.student@pepperdine.edu)
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Disability Specific Information

Below, you will find a list of disabilities. Because there can be significant nuance within each category of disability, it is important for you to help us understand the details of your condition as it affects your education. Please clarify the accommodations you are requesting.
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Is this a temporary or permanent disability?(Required) *


Please include dates
Are you requesting academic accommodation/s?(Required) *
Are you requesting housing accommodation/s?(Required) *

Service Information

Please consider both our Information Release and Policy for Receiving Services.
Release of Information to University Personnel(Required) *
 
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I also give permission for the staff of the Office of Student Accessibility to speak with the following individuals outside of Pepperdine University (this could be a parent or other family member, physician, psychologist, etc.) Please provide appropriate contact information for each individual. 

Policy for Receiving Services(Required) *

It is my responsibility to initiate services with the OSA and to inform my professors of the accommodations for which I have been approved by providing my professors with my accommodation letter each semester.

I understand that I must submit a Semester Request each semester in order to activate my approved accommodations. Once this request is submitted I will receive an updated accommodation letter via email. 

I understand that accommodations are not retroactive to registration with the OSA, and that it is my responsibility to immediately notify the OSA of any disability related problems or concerns I have so that they can be addressed appropriately.

 
Notice of Pepperdine Privacy Practices(Required) *

G. Notice of Privacy Practices

1.  Policy

Pepperdine University is committed to maintaining and protecting the confidentiality of the

individual’s PHI.  This Notice of Privacy Practices applies to Pepperdine University (Athletics,

Boone Center for the Family, Counseling Center, Disability Services Office, Graduate School of

Education and Psychology (PRYDE, Union Rescue Mission, Clinics), Human Resources, and Student Health Center) (“Departments”).  Pepperdine University is required by federal and state law, including the Health Insurance Portability and Accountability Act (“HIPAA”), to protect the

individual’s PHI and other personal information.  Pepperdine is required to provide the individual

with this Notice of Privacy Practices about the University’s policies, safeguards, and practices.  

When Pepperdine University uses or discloses an individual’s PHI, Pepperdine University is bound by the terms of this Notice of Privacy Practices, or the revised Notice of Privacy Practices, if applicable.

 

The University’s Obligations:

Pepperdine is required by law to:

➢➢   Maintain the privacy of PHI (with certain exceptions)

➢➢   Give the individual this notice of the University’s legal duties and privacy practices

regarding health information about the individual

➢➢   Follow the terms of the University’s Notice of Privacy Practice that is currently in effect

 

2.  Procedure

How the University may use and disclose PHI:

The following describes the ways the University may use and disclose PHI.  Except for the purposes described below, the University will use and disclose PHI only with the individual’s written permission.  The individual may revoke such permission at any time by writing to Pepperdine University’s Compliance Officer.

➢➢   For Treatment.  The University may use and disclose PHI for the individual’s treatment and to provide the individual with treatment-­‐related health care services.  For example, the University may disclose PHI to doctors, nurses, technicians, or other personnel, including people outside the University’s office, who are involved in the individual’s medical care and need the information to provide the individual with medical care.

➢➢   For Payment.  The University may use and disclose PHI so that the University or others may bill and receive payment from the individual, an insurance company or a third party for the treatment and services the individual received.  For example, the University may tell the individual’s insurance company about a treatment the individual is going to receive to determine whether the individual’s insurance company will cover the treatment.

➢➢   For Health Care Operations.  The University may use and disclose PHI for health care

operations purposes.  These uses and disclosures are necessary to make sure that all of the

University’s patients receive quality care and to operate and manage the University’s office.  For

example, the University may share information with doctors, residents, nurses, technicians, clerks, and other personnel for quality assurance and educational purposes.  The University also may share information with other entities that have a relationship with the individual (for example, the individual’s insurance company and anyone other than the individual who pays for the individual’s services) for the individual’s health care operation activities.

➢➢   Appointment Reminders, Treatment Alternatives, and Health Related Benefits and Services.  The University may use and disclose PHI to contact the individual to remind them that they have an appointment with the University.  The University also may use and disclose PHI to tell the individual about treatment alternatives or health-­‐related benefits and services that may be of interest to the individual.

➢➢   Third Parties Involved in an Individual’s Care or Payment for an Individual’s Care.  When

appropriate, the University may share PHI with a person who is involved in the individual’s medical care or payment for the individual’s care, such as the individual’s family or a close friend.  The University also may notify the individual’s family about the individual’s location or general condition or disclose such information to an entity (such as the Red Cross) assisting in a disaster relief effort.

➢➢   Research.  Under certain circumstances, the University may use and disclose PHI for research.  For example, a research project may involve comparing the health of patients who received one treatment to those who received another, for the same condition.  The University will generally ask for the individual’s written authorization before using the individual’s PHI or sharing it with others to conduct research. Under limited circumstances, the University may use and disclose PHI for research purposes without the individual’s permission.  Before the University uses or discloses PHI for research without the individual’s permission, the project will go through a special approval process to ensure that research conducted poses minimal risk to the individual’s privacy. The individual’s information will be de-­‐ identified. Researchers may contact the individual to see if the individual is interested in or eligible to participate in a study.

 

SPECIAL SITUATIONS:

➢➢   As Required by Law.  The University will disclose PHI when required to do so by international, federal, state or local law.

➢➢   To Avert a Serious Threat to Health or Safety.  The University may use and disclose PHI when necessary to prevent a serious threat to the individual’s health and safety or the health and safety of others.  Disclosures, however, will be made only to someone who may be able to help prevent or respond to the threat, such as law enforcement or a potential victim. For example, the University may need to disclose information to law enforcement when a patient reveals participation in a violent crime.

➢➢   Business Associates.  The University may disclose PHI to the University’s business associates that perform functions on the University’s behalf or provide the University with services if the information is necessary for such functions or services.  For example, the University may use another company to perform billing services on the University’s behalf. All of the University’s business associates are obligated to protect the privacy of the individual’s information and are not allowed to use or disclose any information other than as specified in our contract.

➢➢   Organ and Tissue Donation.  If the individual is an organ donor, the University may use or

release PHI to organizations that handle organ procurement or other entities engaged in

procurement, banking or transportation or organs, eyes or tissues to facilitate organ, eye or

tissue donation and transplantation.

➢➢   Military and Veterans.  If the individual is a member of the armed forces, the University may release PHI as required by military command authorities.The University also may release PHI to the appropriate foreign military authority if the individual is a member of a foreign military.

➢➢   Workers’ Compensation.  The University may release PHI for workers’ compensation or similar programs.  These programs provide benefits for work-­‐related injuries or illness.

➢➢   Public Health Risks.  The University may disclose PHI for public health risks or certain

occurrences.  These risks and occurrences generally include disclosures to prevent or control

disease, injury or disability; report births and deaths; report child, elder or dependent adult

abuse or neglect; report reactions to medications or problems with products; notify people of

recalls of products they may be using; a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence (we will only make this disclosure when required or authorized by law).

➢➢   Health Oversight Activities.  The University may disclose PHI to a health oversight agency, such as the California Department of Health and Human Services or Center for Medicare and Medical Services, for activities authorized by law.  These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

➢➢   Data Breach Notification Purposes.  The University may use or disclose the individual’s PHI to provide legally required notices of unauthorized access to or disclosure of PHI.

➢➢   Lawsuits and Disputes.  If the individual is involved in a lawsuit or a dispute, the

University may disclose PHI in response to a court or administrative order.  The University also may disclose PHI in response to a subpoena, discovery request, or other lawful request by someone else involved in the dispute, but only if efforts have been made to tell the individual about the request or to allow the individual to obtain an order protecting the information requested.

➢➢   Law Enforcement.  The University may release PHI if asked by a law enforcement official if the information is:  (1) in response to a court order, subpoena, warrant, summons or similar process; (2) limited information to identify or locate a suspect, fugitive, material witness, or missing person; (3) about the victim of a crime even if, under certain very limited circumstances, the University is unable to obtain the individual’s agreement; (4) about a death the University

believes may be the result of criminal conduct; (5) about criminal conduct on the University’s

premises; and (6) in an emergency to report a crime, the location of the crime or victims, or the

identity, description or location of the person who committed the crime.

➢➢   Coroners, Medical Examiners and Funeral Directors.  The University may release PHI to a coroner or medical examiner.  This may be necessary, for example, to identify a deceased person or determine the cause of death.  The University also may release PHI to funeral directors as necessary for their duties.

➢➢   National Security and Intelligence Activities.  The University may release PHI to authorized federal officials for intelligence, counter-­‐intelligence, and other national security activities authorized by law.

➢➢   Protective Services for the President and Others.  The University may disclose PHI to

authorized federal officials so they may provide protection to the President, other authorized

persons or foreign heads of state, or to conduct special investigations.

➢➢   Inmates or Individuals in Custody.  If the individual is an inmate of a correctional

institution or under the custody of a law enforcement official, the University may release PHI to

the correctional institution or law enforcement official.  This release would be necessary if: (1)

for the institution to provide the individual with health care; (2) to protect the individual’s

health and safety or the health and safety of others; or (3) the safety and security of the

correctional institution.

 

USES AND DISCLOSURES THAT REQUIRES THE UNIVERSITY TO GIVE THE INDIVIDUAL AN OPPORTUNITY TO

OBJECT/OPT OUT:

➢➢   Third Parties Involved in the Individual’s Care or Payment for Individual’s Care.  Unless the individual objects, the University may disclose to a member of the individual’s family, a relative, a close friend or any other person the individual identifies, the individual’s PHI that directly relates to that third party’s involvement in the individual’s health care.  If the individual is

unable to agree or object to such a disclosure, the University may disclose such information as

necessary if the University determines that it is in the individual’s best interest based on the

University’s professional judgment.

 

➢➢   Disaster Relief.  The University may disclose the individual’s PHI to disaster relief

organizations that seek the individual’s PHI to coordinate the individual’s care, or notify family

and friends of the individual’s location or condition in a disaster.  The University will provide

the individual with an opportunity to agree or object to such a disclosure whenever the University practically can do so.

➢➢   Fundraising. The University may notify the individual about fundraising events that support Pepperdine University.

 

INDIVIDUAL’S WRITTEN AUTHORIZATION IS REQUIRED FOR OTHER USES AND DISCLOSURES:

The following uses and disclosures of the individual’s PHI will be made only with the individual’s

written authorization:

1.   Uses and disclosures of PHI for marketing purposes;

2.   Disclosures that constitute a sale of the individual’s PHI; and

3.   Disclosures of psychotherapy notes.

➢➢   Other uses and disclosures of PHI not covered by this Notice of Privacy Practice or the laws that apply to the University will be made only with the individual’s written authorization.  If the individual gives us authorization, the individual may revoke it at any time by submitting a written revocation to Pepperdine University Compliance Officer and we will no longer disclose PHI under the authorization.  But disclosure that the University made in reliance on an individual’s authorization before the individual revoked it will not be affected by the revocation.

 

INDIVIDUAL’S RIGHTS REGARDING PHI:

➢➢   Right to Inspect and Copy.  The individual has a right to inspect and copy PHI that may be

used to make decisions about the individual’s care or payment for the individual’s care.  This

includes medical and billing records, other than psychotherapy notes.  To inspect and copy the

individual’s PHI, the individual must make their request, in writing, to the Department in which

their care was provided.  The University has up to 30 days to make the individual PHI available to the individual and the University may charge the individual a reasonable fee for the costs of

copying, mailing or other supplies associated with the individual’s request.  The University may

not charge the individual a fee if the individual needs the information for a claim for benefits

under the Social Security Act or any other state or federal needs-­‐based benefit program.  The

University may deny the individual’s request in certain limited circumstances.  If the University

does deny the individual’s request, the individual has the right to have the denial reviewed by a

licensed healthcare professional that was not directly involved in the denial of the individual’s

request, and the University will comply with the outcome of the review.

➢➢   Right to Get Notice of a Breach. Pepperdine University is committed to safeguarding the

individual’s PHI.  If a breach of the individual’s PHI occurs, the University will notify the individual in accordance with state and federal law.

➢➢   Right to Amend, Correct or Add an Addendum.  If the individual feels that the PHI the

University has is incorrect, incomplete, or the individual wishes to add an addendum to the

individual’s records, the individual has the right to make such request for as long as the

information is kept by or for the University’s office.  The individual must make their request in

writing to the Department in which their care was provided.  In the case of claims that the

information is incorrect, incomplete, or if the record was not created by Pepperdine University,

the University may deny the individual’s request.  However, if the University denies any part of the individual’s request, the University will provide the individual with a written explanation of the reasons for doing so within 60 days of the individual’s request.

➢➢   Right to an Accounting of Disclosures.  Individuals have the right to request a list of

certain disclosures the University made of PHI for purposes other than treatment, payment, health care operations, certain other purposes consistent with law, or for which the individual provided written authorization.  To request an accounting of disclosure, individuals must make their request, in writing, to the Department in which the individual’s care was provided. The

individual may request an accounting of disclosures for up to the previous six years of services

provided before the date of the individual’s request.  If more than one request is made during a 12 month period, Pepperdine University may charge a cost based fee.

➢➢   Right to Request Restrictions.  Individuals have the right to request a restriction or

limitation on the PHI Pepperdine University uses or disclose  for treatment, payment, or health

care operations.  Individuals also have the right to request a limit on the PHI we disclose to

someone involved in the individual’s care or the payment for the individual’s care, like a family

member or friend.  For example, the individual could ask that the University not share information about a particular diagnosis or treatment with the individual’s spouse.  To request a restriction, the individual must make their request, in writing, to the Department in which their care was provided. The University is not required to agree to the individual’s request unless the

individual is asking us to restrict the use and disclosure of the individual’s PHI to a health plan

for payment or health care operation purposes and such information the individual wishes to

restrict pertains solely to a health care item or service for which the individual has paid the

University out-­‐of-­‐pocket in full.  If the University agrees, the University will comply with

the individual’s request unless the information is needed to provide the individual with emergency treatment or to comply with law.  If the University does not agree, the University will provide an explanation in writing.

➢➢   Out-­‐of-­‐Pocket-­‐Payments.  If the individual pays out-­‐of-­‐pocket (or in other words,

the individual has requested that the University not bill the individual’s health plan) in full for

a specific item or service, the individual has the right to ask that the individual’s PHI with

respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and the University will honor that request.

➢➢   Right to Request Confidential Communications.  Individuals have the right to request that the University communicate with them about medical matters in a certain way or at a certain location.  For example, the individual can ask that the University only contact individuals by mail or at work. To request confidential communications, individuals must make their request, in writing, to the Department in which their care was provided.  The individual’s request must specify how or where the individual wishes to be contacted. The University will accommodate reasonable requests.

➢➢   Right to Choose Someone to Act for the Individual.  If the individual gives someone medical power of attorney or if someone is the individual’s legal guardian, that person can exercise the individual’s rights and make choices about the individual’s PHI.  The University will use our best efforts to verify that person has authority to act for the individual before the University takes any action.

➢➢   Right to a Paper Copy of This Notice of Privacy Practices.  Individuals have the right to a

paper copy of this Notice of Privacy Practices.  Individuals may ask the University to give the

individual a copy of this Notice of Privacy Practices at any time.  Even if the individual has

agreed to receive this Notice of Privacy Practices electronically, individuals are still entitled

to a paper copy of this Notice of Privacy Practices.  Individuals may obtain a copy of this Notice

of Privacy Practices on our website at, http://www.pepperdine.edu/provost/content/policies/hipaa_manual_5_201 2.pdf.  To obtain a paper copy of this Notice of Privacy Practices, contact the Department in which the individual’s care was provided.

 

CHANGES TO THIS NOTICE OF PRIVACY PRACTICES:

➢➢   Pepperdine University reserves the right to change this Notice of Privacy Practices and make the new Notice of Privacy Practices apply to PHI the University already has as well as any

information the University receives in the future. The University will post a copy of the

University’s current Notice of Privacy Practice at our office.  The Notice of Privacy Practices

will contain the effective date on the first page, in the top right-­‐hand corner. Individuals will

be sent information regarding the changes via e-­‐mail or via mail on how they can obtain a new

copy.  Individuals will be asked to sign off on the new Notice of Privacy Practices at the

individual’s next scheduled appointment.

 

COMPLAINTS:

➢➢   If an individual believes their privacy rights have been violated, the individual may file a

complaint with Kim Miller, HIPAA Compliance Officer, 24255 Pacific Coast Highway, Malibu, CA  

90263, 310.506.4208.  All complaints must be made in writing.  Individuals may also contact the

Secretary of the Department of Health and Human Services or Director, Office of Civil Rights of the U.S. Department of Health and Human Services.  Please contact the University Compliance Officer if an individual needs assistance locating current contact information. Individuals will not be penalized or retaliated against for

filing a complaint.