Use and Disclosure of Protected Health Information: Difference between revisions

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:#Relates to the past, present, or future physical or mental health or condition of an individual; the provision of healthcare to an individual; or the past, present, or future payment for the provision of healthcare to an individual.
:#Relates to the past, present, or future physical or mental health or condition of an individual; the provision of healthcare to an individual; or the past, present, or future payment for the provision of healthcare to an individual.


Protected Health Information includes genetic information containing individual identifiers which are defined as:
Protected Health Information includes genetic information containing individual identifiers which is defined as:
:#Information about an individual's gentic tests; or
:#Information about an individual's gentic tests; or
:#The genetic tests of family members of the individual; or
:#The genetic tests of family members of the individual; or
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'''Individual''' means the person who is the subject of the protected health information.  Personal representatives of the individual have the same rights as the individuals under HIPAA.  Personal representatives include the legal guardian and anyone else authorized by law to act on behalf of the individual.
'''Individual''' means the person who is the subject of the protected health information.  Personal representatives of the individual have the same rights as the individuals under HIPAA.  Personal representatives include the legal guardian and anyone else authorized by law to act on behalf of the individual.


'''Marketing''' means to make a communication about a product or service that encourages recipients of the communication to purchase or use the product or service. See Use and Disclosure of PHI for Marketing
'''Marketing''' means to make a communication about a product or service that encourages recipients of the communication to purchase or use the product or service. See Use and Disclosure of PHI for Marketing below


'''Research''' means a systematic investigation, including research development, testing and evaluation, designed to develop or contribute to generalized knowledge.  Generalized knowledge is knowledge that can be applied to populations outside the population service by the ACE.  See Use and Disclosure of PHI for Research
'''Research''' means a systematic investigation, including research development, testing and evaluation, designed to develop or contribute to generalized knowledge.  Generalized knowledge is knowledge that can be applied to populations outside the population service by the ACE.  See Use and Disclosure of PHI for Research below


'''Sale of Protected Health Information''' means disclosure of protected health information by a covered entity or business associate, if applicable, where the covered entity or business associate directly or indirectly receives remuneration from or on behalf of the recipient of the protected health information in exchange for the protected health information. See Sale of Protected Health Information
'''Sale of Protected Health Information''' means disclosure of protected health information by a covered entity or business associate, if applicable, where the covered entity or business associate directly or indirectly receives remuneration from or on behalf of the recipient of the protected health information in exchange for the protected health information. See Sale of Protected Health Information below


== Procedures ==
== Procedures ==
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:#Use of their name, location and general condition in the facility directory.
:#Use of their name, location and general condition in the facility directory.
:#Disclosure of religious affiliation to clergy members.
:#Disclosure of religious affiliation to clergy members.
:#Disclosure of PHI to family member, other relative, or close personal friend of the individual, or any other person identified by the individual, the PHI directly relevant to such person's involvement with the individual's care or payment.
:#Disclosure of PHI to family member, other relative, or close personal friend of the individual, or any other person identified by the individual, the PHI directly relevant to such person's involvement with the individual's care or payment, if the individual is available and has the capacity to agree or reject.


Request for restrictions. Individuals may request restrictions on how their health information is used or disclosed for treatment, payment or healthcare operation purposes, or to certain family member or others involved in their care.  Requests for restrictions can be denied, with one exception.  Requests to restrict self-pay account information from being sent to third party payers must be approved if the account is paid in full out of pocket in advance.
===Request for restrictions===  
:#All requests for restrictions must be in writing and shall be forwarded to the Health Information Management Department Manager of Health Information Logistics.  The Privacy Officer shall be notified and shall coordinate the request for restrictions to the Medical Director of Information Technology for approval/disapproval.  If a request for restriction is approved, processes must be implemented to restrict the use or disclosure of the information within the scope of the approved restriction.  Information subject to an approved restriction can be used for emergency treatment if needed, but the healthcare provider cannot further use or disclose the information.
Individuals may request restrictions on how their health information is used or disclosed for treatment, payment or healthcare operation purposes, or to certain family member or others involved in their care.  Requests for restrictions can be denied, with one exception.  Requests to restrict self-pay account information from being sent to third party payers must be approved if the account is paid in full out of pocket in advance.
:#All requests for restrictions must be in writing and shall be forwarded to the Health Information Management Department Manager of Health Information Logistics.  The Privacy Officer shall be notified and shall coordinate the request for restrictions to the Chief Medical Officer for approval/disapproval.  If a request for restriction is approved, processes must be implemented to restrict the use or disclosure of the information within the scope of the approved restriction.  Information subject to an approved restriction can be used for emergency treatment if needed, but the healthcare provider cannot further use or disclose the information.
:#Requests to have medical information removed from a medical information system/medical record will not generally be approved, since records of treatment provided must be kept and made available for several regulatory and business purposes.
:#Requests to have medical information removed from a medical information system/medical record will not generally be approved, since records of treatment provided must be kept and made available for several regulatory and business purposes.


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:##Disclosures to a school, limited to proof of immunization of a student or prospective student, and UNMC has obtained and documented agreement from the parent, legal guardian, or the individual if the individual is an adult or emancipated minor.
:##Disclosures to a school, limited to proof of immunization of a student or prospective student, and UNMC has obtained and documented agreement from the parent, legal guardian, or the individual if the individual is an adult or emancipated minor.
:#Reports of suspected abuse, neglect or domestic violence made by mandatory reporters to governmental agencies authorized by law to receive such reports.
:#Reports of suspected abuse, neglect or domestic violence made by mandatory reporters to governmental agencies authorized by law to receive such reports.
:#Disclosures for law enforcements purposes.  See Use/Disclosure of PHI for Law Enforcement Purposes.
:#Disclosures for law enforcements purposes.  See Use/Disclosure of PHI for Law Enforcement Purposes below
:#Disclosure for health oversight activities authorized by law, such as audits, investigations, licensure or disciplinary actions.
:#Disclosure for health oversight activities authorized by law, such as audits, investigations, licensure or disciplinary actions.
:#Disclosure for judicial or administrative proceedings pursuant to a court or administrative tribunal order or subpoena.
:#Disclosure for judicial or administrative proceedings pursuant to a court or administrative tribunal order or subpoena.
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===Use/Disclosure of PHI for Law Enforcement Purposes===
===Use/Disclosure of PHI for Law Enforcement Purposes===
PHI may be disclosed to law enforcement under the following circumstances:
PHI may be disclosed to law enforcement under the following circumstances:
:#Law requires reporting violent wounds to law enforcement
:#Laws require reporting violent wounds to law enforcement
:#A valid subpoena or warrant is presented (contact the Health Information Management Department during normal business hours, or the Resource Coordinator or Administrator on call after normal business hours)
:#A valid subpoena or warrant is presented.  Contact the Health Information Management Department, UNMC Associate General Counsel for Healthcare or the UNMC Compliance Officer to review the subpoena or warrant.
:#Law enforcement officer wishes to identify or locate a suspect, fugitive, material witness or missing person.  May provide the following information only:  name, address, date and place of birth, social security number, ABO blood type and Rh factor, type of injury date and time of treatment, date of death, and distinguishing characteristics.   
:#Law enforcement officer wishes to identify or locate a suspect, fugitive, material witness or missing person.  May provide the following information only:  name, address, date and place of birth, social security number, ABO blood type and Rh factor, type of injury date and time of treatment, date of death, and distinguishing characteristics.   
:##May not provide DNA information, blood samples, dental records, tissue or other fluid samples
:##May not provide DNA information, blood samples, dental records, tissue or other fluid samples
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:##Non-routine disclosures:  department managers shall review non-routine requests for PHI on an individual basis and verify that minimum necessary requirements are met.
:##Non-routine disclosures:  department managers shall review non-routine requests for PHI on an individual basis and verify that minimum necessary requirements are met.
:#The following uses/disclosures of PHI are not subject to the minimum necessary requirement:
:#The following uses/disclosures of PHI are not subject to the minimum necessary requirement:
:##Disclosure of healthcare providers for treatment purposes
:##Disclosure to healthcare providers for treatment purposes
:##Disclosures required by law
:##Disclosures required by law
:##Disclosures made to the individual or pursuant to an authorization initiated by the individual
:##Disclosures made to the individual or pursuant to an authorization initiated by the individual
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