Disclosure of PHI for Law Enforcement Purposes - Revision history

Afaylor: Update Health Insurance Portability and Accountability Act of 1996 (HIPAA) – appears 2x

2025-09-29T21:19:33Z

Update Health Insurance Portability and Accountability Act of 1996 (HIPAA) – appears 2x

← Older revision		Revision as of 16:19, September 29, 2025
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	To establish guidelines for the disclosure of PHI for law enforcement purposes in accordance with HIPAA and University of Nebraska Medical Center (UNMC) policies.		To establish guidelines for the disclosure of PHI for law enforcement purposes in accordance with HIPAA and University of Nebraska Medical Center (UNMC) policies.
	==Policy==		==Policy==
	UNMC shall disclose protected health information (PHI) for law enforcement purposes in accordance with the requirements of the [https://www.cdc.gov/phlp/~~publications~~/~~topic~~/hipaa.html Health Insurance Portability and Accountability Act of 1996 (HIPAA)] and UNMC policies to maintain confidentiality of PHI and protect patient privacy.		UNMC shall disclose protected health information (PHI) for law enforcement purposes in accordance with the requirements of the [https://www.cdc.gov/phlp/php/resources/health-insurance-portability-and-accountability-act-of-1996-hipaa.html Health Insurance Portability and Accountability Act of 1996 (HIPAA)] and UNMC policies to maintain confidentiality of PHI and protect patient privacy.
	==Procedures==		==Procedures==
	===Disclosure of PHI for Law Enforcement Purposes===		===Disclosure of PHI for Law Enforcement Purposes===
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	*Nebraska Medicine Legal Blood Alcohol Testing policy, ESD 06.005		*Nebraska Medicine Legal Blood Alcohol Testing policy, ESD 06.005
	*Nebraska Medicine Legal Drug/Alcohol Testing policy, PC18		*Nebraska Medicine Legal Drug/Alcohol Testing policy, PC18
	*[https://www.cdc.gov/phlp/~~publications~~/~~topic~~/hipaa.html Health Insurance Portability and Accountability Act of 1996 (HIPAA)]		*[https://www.cdc.gov/phlp/php/resources/health-insurance-portability-and-accountability-act-of-1996-hipaa.html Health Insurance Portability and Accountability Act of 1996 (HIPAA)]

	This page maintained by [mailto:mhurlocker@unmc.edu mh].		This page maintained by [mailto:mhurlocker@unmc.edu mh].

Mhurlocker at 20:03, July 24, 2024

2024-07-24T20:03:59Z

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	'''Effective Date: 10/28/22'''<br />		'''Effective Date: 10/28/22'''<br />
	'''Revised Date: 10/28/22<br />		'''Revised Date: 10/28/22<br />
	Review Date: 07/24/24~~'''~~<br />		'''Review Date: 07/24/24<br />'''
	<br />		<br />
	<big>'''Policy on Disclosure of PHI for Law Enforcement Purposes'''</big><br /><br />		<big>'''Policy on Disclosure of PHI for Law Enforcement Purposes'''</big><br /><br />

Mhurlocker at 20:03, July 24, 2024

2024-07-24T20:03:18Z

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	<br /><br />		<br /><br />
	Policy No.: '''6305'''<br />		Policy No.: '''6305'''<br />
	Effective Date: ~~'''~~10/28/22'''<br />		'''Effective Date: 10/28/22'''<br />
	Revised Date: 10/28/22<br />		'''Revised Date: 10/28/22<br />
	Review Date: 07/24/24<br />		Review Date: 07/24/24'''<br />
	<br />		<br />
	<big>'''Policy on Disclosure of PHI for Law Enforcement Purposes'''</big><br /><br />		<big>'''Policy on Disclosure of PHI for Law Enforcement Purposes'''</big><br /><br />

Mhurlocker at 20:02, July 24, 2024

2024-07-24T20:02:37Z

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	<br /><br />		<br /><br />
	Policy No.: '''6305'''<br />		Policy No.: '''6305'''<br />
	Effective Date: '''~~Draft~~ 10/28/22'''<br />		Effective Date: '''10/28/22'''<br />
	Revised Date: <br />		Revised Date: 10/28/22<br />
	~~Revised~~ Date: <br />		Review Date: 07/24/24<br />
	<br />		<br />
	<big>'''Policy on Disclosure of PHI for Law Enforcement Purposes'''</big><br /><br />		<big>'''Policy on Disclosure of PHI for Law Enforcement Purposes'''</big><br /><br />
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	*Contact [mailto:unmcpublicsafety@unmc.edu Public Safety]; for Emergencies: 402-559-5555, 24 hours per day; for Dispatch: 402-559-5111, 24 hours per day		*Contact [mailto:unmcpublicsafety@unmc.edu Public Safety]; for Emergencies: 402-559-5555, 24 hours per day; for Dispatch: 402-559-5111, 24 hours per day
	*Risk (consult Web On Call or the hospital operator to reach on-call Risk staff)		*Risk (consult Web On Call or the hospital operator to reach on-call Risk staff)
	*General Counsel’s Office ~~(Hospital or University??)~~		*General Counsel’s Office
	*UNMC Policy No. 6045, [https://wiki.unmc.edu/index.php/Privacy/Confidentiality Privacy, Confidentiality and Security of Patient and Proprietary Information]		*UNMC Policy No. 6045, [https://wiki.unmc.edu/index.php/Privacy/Confidentiality Privacy, Confidentiality and Security of Patient and Proprietary Information]
	*UNMC Policy No. 6051, [https://wiki.unmc.edu/index.php/Computer_Use/Electronic_Information Computer Use/Electronic Information]		*UNMC Policy No. 6051, [https://wiki.unmc.edu/index.php/Computer_Use/Electronic_Information Computer Use/Electronic Information]
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	*[https://www.cdc.gov/phlp/publications/topic/hipaa.html Health Insurance Portability and Accountability Act of 1996 (HIPAA)]		*[https://www.cdc.gov/phlp/publications/topic/hipaa.html Health Insurance Portability and Accountability Act of 1996 (HIPAA)]

	This page maintained by [mailto:~~dpanowic~~@unmc.edu ~~dkp~~].		This page maintained by [mailto:mhurlocker@unmc.edu mh].

Mhurlocker: /* Definitions */

2023-08-16T15:01:57Z

Definitions

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	*an Individual’s genetic tests;		*an Individual’s genetic tests;
	*the genetic tests of an Individual’s family members; or		*the genetic tests of an Individual’s family members; or
	*the manifestation of a disease or disorder in such Individual’s family members (i.e., family medical history)~~; or~~		*the manifestation of a disease or disorder in such Individual’s family members (i.e., family medical history).
	*any request for, or receipt of, genetic services (e.g., genetic test, genetic counseling, genetic education), or participation in clinical research which includes genetic services by the Individual or any family member of the Individual.
	PHI excludes:		PHI excludes:
	*individually identifiable health information of a person who has been deceased for more than fifty (50) years.		*individually identifiable health information of a person who has been deceased for more than fifty (50) years.

Dpanowic at 17:07, October 28, 2022

2022-10-28T17:07:14Z

← Older revision		Revision as of 12:07, October 28, 2022
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	<br /><br />		<br /><br />
	Policy No.: '''6305'''<br />		Policy No.: '''6305'''<br />
	Effective Date: '''Draft 09/29/22'''<br />		Effective Date: '''Draft 10/28/22'''<br />
	Revised Date: <br />		Revised Date: <br />
	Revised Date: <br />		Revised Date: <br />
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	==Definitions==		==Definitions==
	===Individual===		===Individual===
	The person who is the subject of the PHI. Personal representatives of the ~~patient~~ have the same rights as the Individual under HIPAA (i.e., they “step into the shoes” of the Individual). Personal representatives include the legal guardian and anyone else authorized by law to act on behalf of the Individual. See Nebraska Medicine Consents and Permits policy, MS14.		The person who is the subject of the PHI. Personal representatives of the Individual have the same rights as the Individual under HIPAA (i.e., they “step into the shoes” of the Individual). Personal representatives include the legal guardian and anyone else authorized by law to act on behalf of the Individual. (See Nebraska Medicine Consents and Permits policy, MS14.)
	===Protected Health Information (PHI)===		===Protected Health Information (PHI)===
	Individually identifiable health information including demographic information, collected from an Individual, whether oral or recorded in any medium, that:		Individually identifiable health information including demographic information, collected from an Individual, whether oral or recorded in any medium, that:
	*is created or received by UNMC/~~Nebraska Medicine~~; and		*is created or received by UNMC/ACE; and
	*relates to the past, present or future physical or mental health or condition of an Individual; the provision of health care to an Individual; or the past, present or future payment for the provision of health care to an Individual and identifies the Individual or with respect to which there is a reasonable basis to believe the information can be used to identify the Individual.		*relates to the past, present or future physical or mental health or condition of an Individual; the provision of health care to an Individual; or the past, present or future payment for the provision of health care to an Individual and identifies the Individual or with respect to which there is a reasonable basis to believe the information can be used to identify the Individual.
	PHI includes genetic information, which includes information about the following items (and excludes information about an Individual’s sex or age):		PHI includes genetic information, which includes information about the following items (and excludes information about an Individual’s sex or age):
	*an Individual’s genetic tests;		*an Individual’s genetic tests;
	*the genetic tests of an Individual’s family members; or		*the genetic tests of an Individual’s family members; or
	*the manifestation of a disease or disorder in such Individual’s family members (i.e., family medical history); or		*the manifestation of a disease or disorder in such Individual’s family members (i.e., family medical history); or
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	PHI excludes:		PHI excludes:
	*individually identifiable health information of a person who has been deceased for more than fifty (50) years.		*individually identifiable health information of a person who has been deceased for more than fifty (50) years.
	*education records covered by the Family Educational Rights and Privacy Act (FERPA); and		*education records covered by the Family Educational Rights and Privacy Act (FERPA); and
	*employment records held by UNMC in its role as employer.		*employment records held by UNMC in its role as employer.
	===Workforce===		===Workforce===
	Employees, medical staff, volunteers, trainees, and other persons whose conduct, in the performance of work for UNMC, is under the direct control of UNMC, whether or not they are paid by UNMC.		Employees, medical staff, volunteers, trainees and other persons whose conduct, in the performance of work for Nebraska Medicine/UNMC, is under the direct control of Nebraska Medicine/UNMC, whether or not they are paid by Nebraska Medicine/UNMC.
	==Additional Information==		==Additional Information==
	*Contact the [mailto:privacy@nebraskamed.com Privacy Office] or at 402-559-5136.		*Contact the [mailto:privacy@nebraskamed.com Privacy Office] or at 402-559-5136.

Dpanowic at 22:02, September 29, 2022

2022-09-29T22:02:05Z

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	[[Identification Card]] \| [[Secure Area Card Access]] \| [[Privacy/Confidentiality]] \| [[Computer Use/Electronic Information]] \| [[Retention and Destruction/Disposal of Private and Confidential Information]] \| [[Use and Disclosure of Protected Health Information]] \| [[Notice of Privacy Practices]] \| [[Access to Designated Record Set]] \| [[Accounting of PHI Disclosures]] \| [[Patient/Consumer Complaints]] \| [[Vendors]] \| [[Fax Transmissions]] \| [[Psychotherapy Notes]] \| [[Facility Security]] \| [[Conditions of Treatment Form]] \| [[Informed Consent for UNMC Media]] \| [[Transporting Protected Health Information]] \| [[Honest Broker]] \| [[Social Security Number]] \| [[Third Party Registry]] \| [[Information Security Awareness and Training]] \| [[Patient Privacy Investigations and Levels of Violation]] \| [[Use and Disclosure of PHI for Training Health Care Professionals]] \| [[Disclosures of PHI as Permitted or Required by Law]] \| [[Disclosure of PHI for Law Enforcement Purposes]]		[[Identification Card]] \| [[Secure Area Card Access]] \| [[Privacy/Confidentiality]] \| [[Computer Use/Electronic Information]] \| [[Retention and Destruction/Disposal of Private and Confidential Information]] \| [[Use and Disclosure of Protected Health Information]] \| [[Notice of Privacy Practices]] \| [[Access to Designated Record Set]] \| [[Accounting of PHI Disclosures]] \| [[Patient/Consumer Complaints]] \| [[Vendors]] \| [[Fax Transmissions]] \| [[Psychotherapy Notes]] \| [[Facility Security]] \| [[Conditions of Treatment Form]] \| [[Informed Consent for UNMC Media]] \| [[Transporting Protected Health Information]] \| [[Honest Broker]] \| [[Social Security Number]] \| [[Third Party Registry]] \| [[Information Security Awareness and Training]] \| [[Patient Privacy Investigations and Levels of Violation]] \| [[Use and Disclosure of PHI for Training Health Care Professionals]] \| [[Disclosures of PHI as Permitted or Required by Law]] \| [[Disclosure of PHI for Law Enforcement Purposes]]
	<br /><br />		<br /><br />
	Policy No.: '''~~6304~~'''<br />		Policy No.: '''6305'''<br />
	Effective Date: '''Draft 08/23/22'''<br />		Effective Date: '''Draft 09/29/22'''<br />
	Revised Date: <br />		Revised Date: <br />
	Revised Date: <br />		Revised Date: <br />

Dpanowic at 17:29, September 26, 2022

2022-09-26T17:29:42Z

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 ==Policy==
 UNMC shall disclose protected health information (PHI) for law enforcement purposes in accordance with the requirements of the [https://www.cdc.gov/phlp/publications/topic/hipaa.html Health Insurance Portability and Accountability Act of 1996 (HIPAA)] and UNMC policies to maintain confidentiality of PHI and protect patient privacy.
 ==Procedures==
 ===Disclosure of PHI for Law Enforcement Purposes===
@@ Line 149: / Line 131: @@
 #**staff is presented a court order, subpoena, or warrant for the test specimen or results (forward the document to the Health Information Management department (HIM) for processing; for urgent requests that cannot wait for HIM, contact Risk or General Counsel’s office).
 Reference Nebraska Medicine’s Legal Blood Alcohol Testing policy, ESD 06.005, and Legal Drug/Alcohol Testing policy, PC18.
+==Definitions==
+===Individual===
 ==Additional Information==
 *Contact the [mailto:privacy@nebraskamed.com Privacy Office] or at 402-559-5136.

Dpanowic at 20:47, August 25, 2022

2022-08-25T20:47:46Z

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	#**The request is specific and limited in scope to the extent reasonably practicable in light of the purpose for which the information is sought; and		#**The request is specific and limited in scope to the extent reasonably practicable in light of the purpose for which the information is sought; and
	#**De-identified information could not reasonably be used.		#**De-identified information could not reasonably be used.
	::<p>'''Note:''' Law enforcement is not permitted to be present in an operating room or any other treatment space unless: </p>		<blockquote>'''Note:''' Law enforcement is not permitted to be present in an operating room or any other treatment space unless: </blockquote>
	#*required by a court order or search warrant;		::*required by a court order or search warrant;
	#*at the request of clinical staff (e.g., for their safety); or		::*at the request of clinical staff (e.g., for their safety); or
	~~###~~*the Individual gives permission for a law enforcement officer to be in the patient’s room (and the law enforcement officer’s presence does not impede or in any way compromise the patient’s medical care, in staff’s sole determination).~~<br />~~		::*the Individual gives permission for a law enforcement officer to be in the patient’s room (and the law enforcement officer’s presence does not impede or in any way compromise the patient’s medical care, in staff’s sole determination).
	~~<ol>~~#~~<li value = '3">~~If a law enforcement officer requests PHI to identify or locate a suspect, fugitive, material witness, or missing person. Staff may provide only the following PHI about the Individual in this scenario:</li>		#If a law enforcement officer requests PHI to identify or locate a suspect, fugitive, material witness, or missing person. Staff may provide only the following PHI about the Individual in this scenario:</li>
	#**name,		#**name,
	#**address,		#**address,

Dpanowic at 20:42, August 25, 2022

2022-08-25T20:42:09Z

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	===Disclosure of PHI for Law Enforcement Purposes===		===Disclosure of PHI for Law Enforcement Purposes===
	In addition to disclosures of PHI that are allowed by UNMC Policy No. 6303, [[Disclosures of PHI as Permitted or Required by Law]], PHI may be disclosed to law enforcement only under the following, limited circumstances. All such disclosures must be documented via Quick Disclosure. Disclosure must be limited to the minimum necessary amount needed to accomplish the disclosure’s intended purpose (which may be the elements listed in a relevant state law).		In addition to disclosures of PHI that are allowed by UNMC Policy No. 6303, [[Disclosures of PHI as Permitted or Required by Law]], PHI may be disclosed to law enforcement only under the following, limited circumstances. All such disclosures must be documented via Quick Disclosure. Disclosure must be limited to the minimum necessary amount needed to accomplish the disclosure’s intended purpose (which may be the elements listed in a relevant state law).
	~~{{ordered list~~
	\|When believed in good faith to be necessary to prevent or '''lessen a serious and imminent threat to the health or safety of a person or the public'''. If law enforcement is to be contacted, first contact campus [https://www.unmc.edu/aboutus/public-safety/index.html Public Safety] (unless the threat is immediate, in which case local law enforcement should be contacted immediately). Reference this policy, UNMC Policy No. 6304, [[Disclosure of PHI for Law Enforcement Purposes]].		#When believed in good faith to be necessary to prevent or '''lessen a serious and imminent threat to the health or safety of a person or the public'''. If law enforcement is to be contacted, first contact campus [https://www.unmc.edu/aboutus/public-safety/index.html Public Safety] (unless the threat is immediate, in which case local law enforcement should be contacted immediately). Reference this policy, UNMC Policy No. 6304, [[Disclosure of PHI for Law Enforcement Purposes]].
	#In compliance with and as limited by the relevant requirements of:		#In compliance with and as limited by the relevant requirements of:
	#*A '''court order''' or '''court-ordered warrant''', or a '''subpoena''' or '''summons issued by a judicial officer''' (reference UNMC Policy No. 6303, [[Disclosures of PHI as Permitted or Required by Law]] regarding disclosures for judicial or administrative proceedings pursuant to a court or administrative tribunal order or subpoena);		#*A '''court order''' or '''court-ordered warrant''', or a '''subpoena''' or '''summons issued by a judicial officer''' (reference UNMC Policy No. 6303, [[Disclosures of PHI as Permitted or Required by Law]] regarding disclosures for judicial or administrative proceedings pursuant to a court or administrative tribunal order or subpoena);
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	#**The information sought is relevant and material to a legitimate law enforcement inquiry;		#**The information sought is relevant and material to a legitimate law enforcement inquiry;
	#**The request is specific and limited in scope to the extent reasonably practicable in light of the purpose for which the information is sought; and		#**The request is specific and limited in scope to the extent reasonably practicable in light of the purpose for which the information is sought; and
	#**De-identified information could not reasonably be used.~~<!--~~		#**De-identified information could not reasonably be used.
	~~-->~~<p>		::<p>'''Note:''' Law enforcement is not permitted to be present in an operating room or any other treatment space unless: </p>
	:'''Note:''' Law enforcement is not permitted to be present in an operating room or any other treatment space unless: </p>		#*required by a court order or search warrant;
	~~:::~~*required by a court order or search warrant;		#*at the request of clinical staff (e.g., for their safety); or
	~~:::~~*at the request of clinical staff (e.g., for their safety); or		###*the Individual gives permission for a law enforcement officer to be in the patient’s room (and the law enforcement officer’s presence does not impede or in any way compromise the patient’s medical care, in staff’s sole determination).<br />
	~~:::~~*the Individual gives permission for a law enforcement officer to be in the patient’s room (and the law enforcement officer’s presence does not impede or in any way compromise the patient’s medical care, in staff’s sole determination).		<ol>#<li value = '3">If a law enforcement officer requests PHI to identify or locate a suspect, fugitive, material witness, or missing person. Staff may provide only the following PHI about the Individual in this scenario:</li>
	<li value="3">#If a law enforcement officer requests PHI to identify or locate a suspect, fugitive, material witness, or missing person. Staff may provide only the following PHI about the Individual in this scenario:</li>
	#**name,		#**name,
	#**address,		#**address,