ACCOUNTING FOR DISCLOSURES OF PROTECTED HEALTH INFORMATION

Transcription

1 Children's Hospital and Regional Medical Center (Administrative Policy/Procedure: IM) ACCOUNTING FOR DISCLOSURES OF PROTECTED HEALTH INFORMATION POLICY: Children s supports the right of patients or their legal representatives to receive an accounting of certain kinds of disclosures of their protected health information (PHI) as provided by the HIPAA Privacy Rule. Children s makes disclosures in accordance with its Use and Disclosure of Protected Health Information policy. Children s tracks PHI disclosures for purposes other than treatment, payment, and health care operations (TPO) made without patient authorization. DEFINITIONS: 1. Protected Health Information is individually identifiable information that relates to the physical or mental health of an individual, the provision of health care to an individual, or the payment for the provision of health care to an individual. This includes (but is not limited to) information such as name, address, date of birth, admission, discharge or death, telephone number, fax number, social security number, medical record number, or account number. 2. Treatment is the provision, coordination, or management of health care and related services by one or more health care providers including the coordination or management of health care by a health care provider with a third party, consultation between health care providers relating to a patient, or the referral of a patient for health care from one health care provider to another. 3. Payment relates to activities undertaken to obtain or provide reimbursement for the provision of health care. 4. Health Care Operations are activities relating to the functions performed by Children s that make it a health care provider. This includes quality assessment and improvement activities; training activities for students, practitioners, and non-health care professionals; accreditation, certification, licensing and credentialing activities; conducting or arranging for medical review, legal services, and auditing functions; business planning and development; and business management and general administrative activities. 5. Treatment, Payment, Health Care Operations activities related to treatment, payment and health care operations as defined above. 6. Disclose and Disclosure mean, with respect to PHI, the release, transfer, provision of access to, or divulging in any other manner of PHI outside Children s. PROCEDURE: 1. Patient s Right to Accounting of Disclosures of PHI A. Patients or their legal representatives have the right to receive an accounting of disclosures made by Children s or its business associates for six years (or less if the individual requests a shorter time period) from the date of the request. Accounting for disclosures of PHI 2004 Children's Hospital and Regional Medical Center All Rights Reserved

2 Page 2: Administrative Policy/Procedure: ACCOUNTING FOR DISCLOSURES OF PHI Patients seeking an accounting shall be directed to make their request in writing to Children s Health Information Department. B. The types of disclosures that will be reported within an accounting include disclosures: For public health activities; For victims of abuse, neglect/domestic violence; For health oversight activities; For judicial or administrative proceedings; For law enforcement purposes; For decedents; For cadaver organ, eye, or tissue donation purposes; For research purposes; To avert a serious threat to health or safety; For specialized government functions; or For workers compensation cases. C. Some disclosures need not be included in an accounting. These include disclosures made: 1) Prior to April 14, 2003; 2) To carry out TPO; 3) To individuals about themselves; 4) Incidental to a use or disclosure otherwise permitted or required for TPO; 5) To carry out an individual s authorization; 6) From Children s facility directory (for more information, see Use and Disclosure of Protected Health Information policy); 7) To persons involved in the individual s care; 8) For purposes of notifying the person responsible for the individual s care and for which the individual had an opportunity to agree or object; 9) For national security or intelligence purposes; 10) To correctional institutions or law enforcement in custodial situations, and 11) Of a limited data set in accordance with a specific data use agreement. D. Children s shall temporarily suspend a patient s right to receive information about disclosures made to a health oversight agency or law enforcement official if requested to do so by that agency. (See procedure described in 5 below.) 2. Content of Accounting for Disclosures Children s shall provide the patient with a written accounting that includes: A. A report of PHI disclosures that occurred during the six year period (or less if the individual requests a shorter time frame) prior to the date of the request or since April 14, 2003, whichever is less. B. Disclosures to, or by, Children s business associates.

3 Page 3: Administrative Policy/Procedure: ACCOUNTING FOR DISCLOSURES OF PHI C. For each disclosure, the following four elements: 1) Date of the disclosure; 2) Name and address (if known) of the facility or person who received the PHI; 3) Brief description of the PHI disclosed; 4) Brief purpose statement that reasonably informs the patient of the basis for the disclosure, or, in lieu of such statement: a. A copy of a written request for a disclosure made by the Secretary of Health & Human Services for compliance review purposes; or b. A copy of a written request for a disclosure that is required by law. 3. Providing the Accounting of Disclosures A. The Children s facility that receives the initial request for an accounting of disclosures determines with the requestor whether or not to include other Children s facilities in the accounting. (Example: For a patient who has been seen at a regional clinic and at the Hospital, the requestor shall be asked whether the accounting should list disclosures made by both facilities or only by one specified facility.) If the requestor specifies an accounting from more than one Children s facility, the facility receiving the request will facilitate the process. If the Hospital is involved, the Health Information Department will coordinate the accounting. B. Children s shall respond to a patient or legal representative s request for an accounting of disclosures within 60 days of receiving the request. C. If Children s is unable to provide the accounting within 60 days of the request, then a single 30-day extension may be made if Children s provides the requestor, in writing, the reason for the delay and the expected date the accounting will be provided. D. Children s shall not charge for the first accounting of disclosures in any 12-month period. E. Children s may impose a reasonable charge for any additional requests made by the same requestor within the same 12-month period. If a charge is to be imposed, Children s will provide the requestor: 1) Advance notice of the fee, and 2) The opportunity to withdraw or modify the request. F. Children s will maintain a copy of the written accounting provided to the individual for six years from the date of its creation.

4 Page 4: Administrative Policy/Procedure: ACCOUNTING FOR DISCLOSURES OF PHI 4. Documentation Requirements for an Accounting of Disclosures A. Each Children s facility shall designate the title of the person or office responsible for receiving and processing requests for accounting of disclosures, and shall retain the written and/or electronic documentation for a minimum of six (6) years. B. Children s maintains a record of all requests for accountings of disclosure, the disposition of those requests, their written and/or electronic documentation, and retains the following: 1) All information listed in 2 above; 2) The written accounting that Children s provided; 3) The titles of the persons or offices responsible for receiving and processing requests for accounting of disclosures. C. The original request for disclosure of information will be retained in the patient s health record for as long as the record exists. 5. Suspending a Patient s Right to an Accounting of Disclosures A. If a health oversight agency or law enforcement official has requested temporary suspension, Children s will not include such disclosures in an accounting. B. Requests from health oversight agencies or law enforcement officials for temporary suspension of a patient s right to receive an accounting of disclosures will typically be made in writing. The request will specify the time for which suspension is required and the reason for such a suspension. C. If the agency makes an oral request for suspension, Children s Health Information Department will document the request including the identity of the agency making the request. D. An oral request for temporary suspension will be limited to 30-days from the date of the oral request. 6. Tracking Reportable Disclosures Refer to the Use & Disclosure of Protected Health Information policy for the procedure for tracking reportable disclosures.

5 Page 5: Administrative Policy/Procedure: ACCOUNTING FOR DISCLOSURES OF PHI References: 45 CFR Part 160 and 164; sections Accounting of Disclosures of Protected Health Information and Administrative Requirements. WAC Medical Record Copying Charges RCW Disclosure by Healthcare Provider Submitted by: Health Information Department, Sue Stubbs Privacy & Security Committee Revised by: Privacy & Security Committee APPROVED BY: _Pat Hagan Chief Operating Officer 10/08/2004 Date ORIGINATED: 04/09/03 REVIEWED: REVISED: 10/08/2004 Additional Key Words: Confidentiality; HIPAA; Privacy; Regulatory.