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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

Policy No.: 6058
Effective Date: 03/17/03
Revised Date: draft 09/22/22
Reviewed Date:

Notice of Privacy Practices Policy

Basis for Policy

It is the policy of the University of Nebraska Medical Center (UNMC) to use and disclose protected health information in accordance with Health Insurance Portability and Accountability Act of 1996 (HIPAA) requirements and University of Nebraska Executive Memorandum No. 27.

Policy

UNMC shall maintain, distribute and post a Notice of Privacy Practices (Notice) in accordance with this policy.

UNMC shall make a good faith effort to obtain a written acknowledgement of receipt of its Notice or document its good faith efforts to do so (and, if applicable, the reason why the acknowledgement was not obtained).

UNMC will provide a joint Notice and obtain the written acknowledgement on behalf of the Organized Health Care Arrangement (OHCA).

Procedure

Notice of Privacy Practices (Notice)

UNMC will adopt and follow a written Notice that meets the requirements of HIPAA’s Privacy Rule. The description of information practices, UNMC’s responsibilities and Individual rights contained in the Notice will govern UNMC’s conduct unless and until the Notice is revised and the revised Notice is posted and the updates are effective. Any revised Notice shall be made available to Individuals upon request. The Notice will be available in the following languages: English and Spanish. Other translations may be made available upon request.

Revisions to Notice

If there is a material change to UNMC’s uses or disclosures of Protected Health Information (PHI), an Individual’s rights with respect to PHI, UNMC’s legal duties with respect to PHI, or other privacy practices stated in the Notice, UNMC will revise the Notice to reflect the change. The Privacy Officer shall be responsible for implementing any changes to the Notice. UNMC will make any revised Notice available upon request on or after the effective date of the revision(s). The Privacy Officer shall retain copies of all versions of the Notice, and will substitute any revised Notice in all of UNMC’s postings and in all supplies made available at service delivery sites.

Posting and Distribution

UNMC will post and distribute its Notice as follows:

• Except in emergency treatment situations (as described below), patient registration personnel shall provide the Notice to the Individual during the registration process. The Notice shall be provided no later than the date of first service encounter. If an Individual’s first service encounter is delivered electronically, such as via telehealth visit, an electronic version of the Notice will be delivered electronically via e-check in and thereafter in writing if the Individual requests a written copy.
• The Notice is not required to be provided for subsequent encounters (other than upon an Individual’s request) if the current Notice was provided at an earlier encounter and such provision can be determined from documentation in the electronic medical record.
• In emergency treatment situations (as determined by registration personnel), the Individual will be given the Notice as soon as reasonably practical after the emergency treatment situation. Registration personnel shall attempt to provide the Notice during the next visit when the electronic health record field shows the Notice was not provided during the previous visit.
• UNMC will prominently post its Notice on its website and make the Notice available electronically through the website.
• UNMC also will post the Notice in a clear and prominent location at service sites where it is reasonable to expect Individuals seeking services from UNMC to be able to read the Notice. The Privacy Officer will approve all posting locations.
• UNMC will maintain a supply of its current Notice at each service delivery site and provide copies of the Notice to Individuals upon request.

Acknowledgement

UNMC will make a good faith effort to obtain the Individual’s written acknowledgment of receipt of the Notice (whether in paper or electronic form), as follows:

• Except in an emergency treatment situation, UNMC shall obtain an Individual’s written acknowledgement of receipt of the Notice in the Conditions of Treatment form when the Notice is provided.
• If UNMC is unable to obtain an Individual’s written acknowledgement, registration personnel shall document the good faith effort to obtain such acknowledgement and the reason why the acknowledgement was not obtained on the Conditions of Treatment form.
• If the Notice is delivered electronically, the Individual's acknowledgement of receipt of the Notice will be documented in the electronic medical record.
• If UNMC distributes a revised Notice, it will follow the preceding steps to obtain written acknowledgment of receipt of the revised Notice.

Documentation

UNMC will maintain the following documentation of the Notice and acknowledgment process:

• A copy of each Notice posted and distributed by UNMC and the effective date of each Notice.
• The delivery date of the Notice, whether in paper or electronic format, to each Individual.
• Each written acknowledgment of receipt of the Notice(s) obtained, whether in paper or electronic format, from an Individual (or documentation of good faith efforts to obtain such written acknowledgement whenever such acknowledgment is not received).

Indirect Treatment Relationships

The Privacy Officer, working with the department director, area manager or supervisor, may identify certain service sites, certain lines of business or certain encounters as being subject to the rules applicable to covered health care providers with indirect treatment relationships. In such cases, the Privacy Officer may approve protocols under which the distribution and acknowledgment requirements of this policy are waived as to encounters that are indirect treatment relationships.

• Specimen account laboratory services shall be considered indirect treatment services.

Organized Health Care Arrangement (OHCA)

UNMC participates in an organized health care arrangement with the medical staffs of Nebraska Pediatric Practice, Inc. and University Dental Associates. Its Notice will be written as a joint Notice covering UNMC and the other participants in relation to their information practices at UNMC.

Definitions

Individual

The person who is the subject of the Protected Health Information (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.

Notice of Privacy Practices (Notice)

A plain language notice of the uses and disclosures that UNMC may make of the Individual’s PHI, and the Individual’s rights and UNMC’s legal duties with respect to such PHI.

Organized Health Care Arrangement (OHCA)

An arrangement among UNMC and members of the medical staff to follow certain common information practices with respect to clinical encounters at UNMC. The OHCA does not encompass the private office practice of participating practitioners or their information practices from other care settings.

Personal Representative

A person who, under HIPAA or State law, is empowered to act or exercise rights on behalf of an Individual. (see Nebraska Medicine’s Consents and Permits policy, MS14, for additional information.)

Protected Health Information (PHI)

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/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.

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;
• 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
• 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:

• 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
• employment records held by UNMC in its role as employer.

Additional Information

• Contact the Privacy Officer
• Notice of Privacy Practices
• Notificación de Prácticas Para Asegurar su Privacidad
• University of Nebraska Executive Memorandum No. 27
• Nebraska Medicine’s Consents and Permits policy, MS14
• Health Insurance Portability and Accountability Act of 1996 (HIPAA)

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