The purpose of this policy is to describe the policy and procedure for requesting and approving access for authorizing short-term access to patient care areas or to view patient care.

Pacific University has established a comprehensive HIPAA privacy and security program to prevent unauthorized access to protected health information (PHI). This policy sets forth Pacific's approach for any person, invited or otherwise authorized to enter Pacific University patient-care areas or to view patient care in any Pacific University Healthcare clinical location, who is not formally associated with the Pacific University Healthcare clinical workforce.

Any person, invited or otherwise authorized to enter Pacific University Healthcare Clinic patient-care areas or to view patient care in any Pacific University Healthcare clinical location, who is not formally associated with the Pacific University Healthcare clinical workforce, must be accounted for, either by a formal registration process, or a more informal approval process for short-term access to patient care areas. Such visitors must be accompanied and/or supervised by a Pacific University representative from the patient care area or location at all times. The Pacific University Healthcare Clinic representative is responsible for the actions of the visitor, including any direct or indirect access to protected health information (PHI).

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Updated February 2023.

Form - Request to Observe Patient Care

Form - Request to Volunteer

Form - Pacific University Healthcare Clinic HIPAA Information Guide

Required document for providing a Job Shadow opportunity as a learning experience to a minor student. Form must be signed.

Updated 3-8-2022

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The purpose of this policy is to establish Pacific University's compliance with federal HIPAA regulations 45 CFR §§ 164.502(b) and 164.514(d), which require covered entities to make reasonable efforts to limit the use and disclosure of PHI to the minimum necessary. Information systems, including electronic health records contain more protected health information (PHI) than may be needed for a given purpose or disclosure. This policy governs the use and disclosure of PHI so that only the minimum amount of PHI is used when needed.

The scope of this policy is all workforce members of Pacific University’s health care component. Pacific University is a hybrid entity. Only the health care component (i.e., the covered functions) of Pacific University must comply with this policy. All references in this policy to “Pacific University” shall be construed to refer only to the health care component of Pacific University.

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Updated April 2023

In accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Pacific University patients may complain about how Pacific University uses and discloses their Protected Health Information (PHI). All patient complaints will be submitted to the HIPAA Privacy Officer for investigation and resolution. (See the policy document for procedures on submitting a complaint.)

Pacific University has established a comprehensive HIPAA privacy and security program to prevent unauthorized access to protected health information (PHI). This policy sets forth Pacific's approach to investigating and responding to patient complaints about privacy practices. This policy applies to the workforce members of Pacific University’s Healthcare Clinics.  Pacific University is a hybrid entity. Only the health care component (i.e., the covered functions) of Pacific University must comply with this policy. All references in this policy to “Pacific University” shall be construed to refer only to the health care components of Pacific University.

Updated August 2023

The purpose of this policy is to describe the patient right to request a restriction of use and disclosure of protected health information (PHI). HIPAA permits a patient to request that the covered entity restrict uses or disclosures of protected health information (PHI) about the patient to carry out treatment, payment, or health care operations.

The scope of this policy is all workforce members of Pacific University’s health care component. Pacific University is a hybrid entity. Only the health care component (i.e., the covered functions) of Pacific University must comply with this policy. All references in this policy to “Pacific University” shall be construed to refer only to the health care component of Pacific University.

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Updated March 2023

Form - Request for Restriction Not to Bill Health Plan or Insurance (Updated August 2023)

Form - Request for Restrictions of Use and Disclosure of Protected Health Information (Updated September 2023)

The purpose of this policy is to describe a patient’s right to request an amendment of protected health information contained in the designated record set (DRS), and the process and timeline for replying to the request. HIPAA provides patients and their representatives certain rights. This policy describes a patient’s right to request an amendment of protected health information (PHI).

The scope of this policy is all workforce members of Pacific University’s health care component. Pacific University is a hybrid entity. Only the health care component (i.e., the covered functions) of Pacific University must comply with this policy. All references in this policy to “Pacific University” shall be construed to refer only to the health care component of Pacific University.

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Updated August 2023

Form - Request to Amend PHI (Updated August 2023)

The purpose of this standard is to define approved methods for using box.com to ensure the integrity and confidentiality of protected health information (PHI) and other Pacific University confidential information while at rest and during transmission. This standard applies to all data that is considered Pacific University confidential information, including PHI, and is being stored in Box, regardless of its storage duration.

Business and instructional needs may require the storage of PHI in the box.com file storage and sharing service (Box). Box provides tools to ensure that PHI remains private and secure. This standard is designed to provide guidelines to Box users who are storing, sharing or accessing PHI in Box, to make best use of those tools to ensure the integrity, privacy and security of that information.

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Updated September 2023

The purpose of this standard is to define approved methods for using encryption technology to ensure the integrity and confidentiality of electronic protected health information (ePHI) and other Pacific University confidential information while at rest and during transmission. This standard applies to all data that is considered Pacific University confidential information, including ePHI when it is at rest, being processed, or transmitted between information technology resources.

Data encryption technology and mechanisms exist to help ensure the confidentiality and integrity of data.  This standard is designed to help Pacific University’s UIS Department determine when it is necessary to utilize encryption, and what type and/or level of encryption to employ. Pacific University security standards for Encryption Technology are based upon industry standards, HIPAA, National Institute of Standards & Technologies (NIST) security guidelines, and existing Pacific University policies on Information Security.

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Revised 2/8/2022

This standard establishes a consistent set of minimum security measures required for computer workstations used within Pacific University. This standard also addresses standards for vendor and personally owned workstations when they are connected to Pacific University’s systems and networks.The elements of this standard include requirements for installation and configuration, access control, physical security, document storage, logging and monitoring, and change management. Pacific University security standards are based upon industry standards, HIPAA, National Institute of Standards & Technologies (NIST) security guidelines, and existing Pacific University policies on Information Security.

This standard applies to all Clinical workstation connected to the Pacific University network. All clinical workstations deployed run Windows and will be configured to policy requirements.

Updated 3-08-2022

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The purpose of this Policy is to set forth Pacific University’s process for applying sanctions for violations of Health Insurance Portability and Accountability Act (HIPAA) Privacy and Security policies. Pacific University has established a comprehensive HIPAA privacy and security program to prevent unauthorized access to protected health information (PHI). This policy sets forth Pacific's approach to applying consistent sanctions upon completion of investigations. 

This policy applies to the workforce members of Pacific University’s Healthcare Clinics. Pacific University is a hybrid entity. Only the health care component (i.e., the covered functions) of Pacific University must comply with this policy. All references in this policy to “Pacific University” shall be construed to refer only to the health care components of Pacific University.

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Updated March 2023

Pacific University Sanctions MATRIX

The Posthumous Degree Policy articulates the criteria by which a posthumous degree can be awarded.

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The Inactivation of Courses Policy allows for the inactivation of courses that have not been offered in four years. Each year in early spring as part of the catalog update process, the Registrar’s Office will forward to each academic unit courses from that unit that have not been offered in 4 years, for review for inactivation.  Certain courses that may be offered infrequently, such as New/Special Topics courses, Internships and Independent Studies, will be excluded from the list.  If the program does not request that a certain course be kept active, the course will be inactivated when the catalog information is updated. If it is desired at a later date to reactivate the course, the unit will inform its curriculum approval entity, and then notify the Registrar’s Office to reactivate.

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The Deceased Student Records Policy articulates when and how education records of a deceased student can be released.

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Updated July 2024

In recognition of the important work that Pacific University employees conduct at conferences, presentations, site visits, development trips, and more, the University Travel Policy provides a way to ensure cost effectiveness and accountability while upholding Pacific University’s mission.

This policy has been created to govern spending on travel and expenses related directly to business travel for Pacific University, in compliance with IRS regulations. The University will reimburse individuals for reasonable, necessary, appropriate and approved travel and business expenses incurred in the performance of University business.

All employees must receive approval from their supervisor before traveling to conferences, workshops, and other off-campus events. Documentation showing this approval may differ for some areas and employees should consult their supervisor. If an area does not have a current system in place employees may utilize a Travel Authorization Form (TAF). For travel to other campuses, prior approval is not necessary.

Prior approval must be documented prior to arranging any travel. The University may not reimburse travel plans made without prior approval from the employee’s supervisor. A purchase order is not required for travel expenses.

In adherence with IRS guidelines, when the employee returns from their travel, they are required to submit a Travel Expense Report to the Business Office with the proper documentation and approval paperwork, within 30 days. The 30-day rule is necessary to allow for processing, and given the IRS may now consider later-filed reimbursements as taxable income to the employee and subject to income and withholding taxes, employees are asked to adhere to this deadline. However, fiscal year-end deadlines set by the Business Office may impact this 30-day requirement and forms may be required to be submitted in less than 30 days.

*Note - Policy document was updated on 2/1/19 to clarify procedures related to obtaining travel insurance.

Travel Authorization Form - June 2019

Travel Expense Report & Reconciliation Form - June 2019

Travel Insurance Information, updated 2/1/19  (for questions related to university insurance, contact the executive assistant to the VP of Finance)

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Grounded in the core theme of educating for student success, Individual Development Plans intend to guide graduate and postdoctoral students in their professional development and career planning.

Graduate students and post-doctoral researchers supported by funding from the National Institutes of Health (NIH) are required to develop Individual Development Plans (IDP). Required progress reports submitted to the NIH must include a copy of the University’s IDP policy, a description of whether the university uses IDPs, and how IDPs are used to assist in the career development of graduate students and postdoctoral researchers supported by NIH.  

Pacific University encourages graduate students and postdoctoral researchers to create and use IDPs to formulate academic and career goals and facilitate conversations with faculty advisors and mentors. All graduate students and postdoctoral researchers supported by NIH funding are required to have an IDP. The Office of Scholarship and Sponsored Projects offers graduate students, postdoctoral researchers, faculty advisors and mentors information on IDP resources, including templates and online resources.

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Pacific University utilizes a variety of IT equipment to support patient care and communicate with healthcare information systems including desktop computers, servers, laptops, and biomedical devices. Biomedical devices typically measure physiological characteristics of patients and in some cases may not use or look like a traditional computer, yet they may store electronic protected healthcare information (ePHI).

Policy addresses security of devices/equipment while in use by Pacific workforce. Details encryption and physical safety measures as well as removal of PHI from devices.

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Pacific University has adopted this Data Integrity Policy and Procedure to ensure the confidentiality, integrity, and availability of all Protected Data we create, receive, maintain, or transmit as required by federal or state regulatory requirements, including but not limited to FERPA, GLBA, HIPAA, PCI, and other regional or local applicable laws and requirements.

The policy establishes a standard to instruct and guide workforce members in the appropriate access, use, storage, and transmission of protected data. Policy requires audits of user access rights to protected data. The university will leverage appropriate security safeguards to support the integrity of Protected Data.

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In support of the physical security safeguards described in NIST standards, Pacific University will implement policies and procedures to prevent unauthorized access to facilities and document the repairs and modifications to the physical components of a facility related to Protected Data security (for example, hardware, walls, doors and locks). This includes access to defined spaces as well as maintenance performed on equipment.

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