University of Nebraska Medical Center

Notice of Privacy Practices

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Policy No.: 6058
Effective Date: 03/17/03
Revised Date: 10/08/19 DRAFT
Reviewed Date:

Notice of Privacy Practices Policy

NOTE: These guidelines are provided to assist the UNMC workforce in complying with HIPAA regulations.

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 Executive Memorandum No. 27.

Policy

Patients receiving treatment at UNMC shall receive the joint Notice of Privacy Practices that describes how Protected Health Information (PHI) about them may be used and disclosed and their rights regarding PHI.

Definitions

Direct Treatment – a treatment relationship in which the health care provider delivers care based on his/her own orders and typically provides services or products, or reports the diagnosis or results associated with the health care directly to the patient rather than through another health care provider (an indirect treatment relationship).

Notice of Privacy Practices (NPP) is a document notifying individuals receiving direct treatment at UNMC about the uses and disclosures of their PHI and their rights regarding PHI. The NPP shall be written in plain language and contain the following elements:

  • A header that must read: “THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.”
  • A list of the covered entities and classes of service delivery sites the joint notice covers
  • A description of uses and disclosures of PHI expected to be made without individual authorization
  • A statement that all other uses and disclosures would be made with the individual’s authorization and that the individual can revoke such authorization
  • Descriptions of the individual’s rights to request restrictions, inspect and copy PHI, amend or correct PHI, and receive an accounting of disclosures of PHI
  • Statements about the entities’ legal requirements to protect privacy, provide notice and adhere to the notice
  • A statement about how the individual would be informed of changes to the joint NPP
  • Instructions on how to make complaints with UNMC or the Secretary of the Department of Health and Human Services
  • Name and telephone number of a contact person to answer questions regarding the NPP
  • The date the NPP is effective

Protected Health Information (PHI) is individually identifiable health information. Health information means any information, whether oral or recorded in any medium, that:

  • is created or received by UNMC; 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.

Records containing PHI, in any form, are the property of UNMC/Nebraska Medicine. The PHI contained in the record is the property of the individual who is the subject of the record.

Procedure

  • Patient registration personnel shall provide the NPP to the patient during the registration process. The NPP shall be provided no later than the date of first direct treatment service delivery, including service delivered electronically (attach NPP to E-mail). If the health care provider's first direct treatment encounter is over the telephone, the NPP shall be mailed to the patient no later than the day of that service delivery. The NPP does not need to be provided during each episode of care. In emergency situations (as determined by Patient Registration personnel), the patient will be given the NPP as soon as reasonably practical after the emergency.
  • Laboratory services shall be considered indirect treatment services.
  • All other services shall be considered direct treatment services.
  • The point of service shall be responsible for providing the patient with the NPP and obtaining acknowledgement of receipt when the patient has been pre-registered.
  • The patient shall sign the acknowledgement of NPP receipt statement contained in the Conditions of Treatment form. A good faith effort shall be made to provide the patient with the NPP. If the NPP is unable to be delivered to the patient, patient registration personnel shall document the good faith effort to deliver the NPP on the Conditions of Treatment form. In emergency situations, patient registration personnel are not required to make and document the good faith effort to deliver the NPP. If the NPP is delivered electronically, documentation of the patient's receipt of the electronic transmission must be filed in the medical record.
  • Patient registration/Point of service personnel shall update the "NPP field" in the electronic health record with a “Received” (NPP provided), “Good Faith” (NPP not provided, i.e. preregistration), or “Good Faith” when the patient registers. Patient Registration/Point of service personnel shall attempt to provide the NPP during the next visit when the electronic health record field shows good faith attempt made, on the previous visit.
  • The NPP shall be placed on the entities' web sites and publicly posted in all patient registration areas in both English and Spanish. Other translations will be made available upon request.
  • If the entities' privacy practices materially change, the NPP will be revised to reflect the changes, as appropriate. The Privacy Officer shall be responsible for implementing the changes. Patients may receive the changed NPP upon request. The Privacy Officer shall retain copies of all versions of the NPP.

Additional Information

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