Hipaa Privacy Rule

Updated: over a week ago

HIPAA Privacy Rule

Use And Disclosure: General Rules

1. Consent is implied for treatment, payment and health care operations; no written authorization is required except for psychotherapy notes. 164.506


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2. Authorizations are required for all other uses or disclosures (including uses or disclosures of psychotherapy notes). For most marketing activities; sale of protected health information; etc. a valid authorization must be included.164.508


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3. Providing notice and chance for patient to agree or object is sufficient for certain disclosures (including disclosures to family members or those involved in the patient’s care), for facility directories and to provide notice in emergency situations. 164.510


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4. Certain disclosures such as those required by law; to avert a serious and imminent health; for public health activities; in response to a court order or subpoena; to law enforcement, etc may be made per regulatory exceptions subject to specific conditions. 164.512


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Use And Disclosure: Special Rules

1. Fund raising uses or disclosures generally require authorization except in certain circumstances. 164.514(f)


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2. Research generally requires authorization unless certain conditions are met. 164.512(i)


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3. Privacy protection continues after death for a period of 50 years. 164.502(f)


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4. Personal representatives and parents of unemancipated minors are generally entitled to access information and exercise other patient rights, subject to certain exceptions. 164.502(g)


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5. Covered entities should verify a requesting person’s identity and authority before disclosing information. 164.514(h)


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6. Covered entities may “de-identify” information, thereby avoiding HIPAA restrictions. 164.502(d), 164.514(e)


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7. Safeguards for facsimiles, e-mails, and telephone communications may be appropriate. Though not expressly required by regulations, but may help satisfy safeguards per 164.530(c).


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Minimum Necessary Standard

1. Use or disclosure must be limited to the minimum necessary to accomplish the purpose, subject to specified situations. 164.502(b)


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2. Define and limit workforce members’ access to protected information. 164.514(d)


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3. Establish protocols for routine disclosures, and processes for handling others on an individual basis. 164.514(d)


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4. Establish protocols for routine requests for information, and processes for handling others on an individual basis. 164.514(d)


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5. The entire record should not be requested, if not necessary. 164.514(d)


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Patient Rights

1. Right to request additional restrictions on use or disclosure for treatment, payment or health care operations; however, the provider is not obligated to agree to restrictions except in limited situation. 164.522(a)


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2. Right to request alternative means or location of communications, including process for requesting alternatives and limitations on requests. 164.522(b)


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3. Right to access protected health information, including process for requesting access; time limits and process for responding; bases for denials; and determination of reasonable costs. 164.524


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4. Right to amend protected health info, including process for requesting amendments; time limits and process for responding; bases and process for denials; attaching amendments or requests; and notifying others about requests. 164.526


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5. Right to request accounting of protected health information, including process for capturing information for accounting; process for requesting accounting; time limits and process for responding; and limitations on requests. 164.528


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Notice Of Privacy Practices

1. Provision and posting of notice. 164.520


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2. Good faith efforts to obtain acknowledgment. 164.520


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Business Associates

1. Process for obtaining business associate contracts; taking action for violations; and obtaining information from business associates to comply with provider’s responsibilities. 164.502(e); 164.504(e)


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Notification Requirements For Breaches Of Unsecured Protected Health Information

1. Identifying when a breach occurs. 164.402


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2. Securing protected health information. 164.402


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3. Notice to individuals, including timing, content, and providing substitute notice. 164.404


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4. Notice to HHS, including annual and immediate notices to HHS, timing, and content. The HHS electronic reporting process 164.408


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5. Notice to the media, including form, timing and content. 164.406


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6. Notice by business associates, including timing and required information. 164.410


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7. Delay in notice at request of law enforcement. 164.412


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Administrative Requirements

1. Designation of privacy offer and contact person. 164.530(a)


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2. Training existing and new members of the workforce. 164.530(b)


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3. Use of technical, administrative, and physical safeguards to avoid improper or incidental disclosures. 164.530(c)


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4. Sanctions against workforce members for violation of policies and regulations. 164.530(e)


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5. Patient complaints, including the process for complaining and responding to complaints. 164.530(d)


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6. Mitigation of improper disclosures. 164.530(f)


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7. Correction of any violations within 30 days to avoid penalties. 160.410


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8. No retaliation or intimidation against patients or others who exercise HIPAA rights. 164.530(g)


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9. No conditioning treatment on a waiver of HIPAA rights. 164.530(h)


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10. Document retention, including identifying documents that must be retained and period of retention. 164.530(i)


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11. Privacy officer designation. 164.530(a)


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12. Contact officer designation. 164.530(a)


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13. Employee training certification. 164.530(b)


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14. Complaint form / action on complaint. 164.530(d)


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15. Privacy violation report form / action in response to incident (including documentation of sanctions). 164.530(f)


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16. Log of breaches reportable to HHS on annual basis. 164.408


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Forms

1. Notice of privacy practices. 164.520


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2. Acknowledgment of receipt of privacy practices. 164.520


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3. Business associate contract. 164.504(e)


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4. Data use agreement (if used). 164.514(e)


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Use And Disclosure Forms

1. Authorization 164.508(c)


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2. Objection to disclosure per 164.510.


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3. Opt-out of fundraising. 164.514(f)


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Patient Rights Forms

1. Request for additional restrictions on use or disclosure / denial of request. 164.522(a)


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2. Request for alternative means or location for communication / action on request. 164.522(b)


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3. Request for access to information / action on request. 164.524; 164.524(d)


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4. Request for amendment of information / action on request. 164.526; 164.526(d)


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5. Request for accounting of information / action on request. Accounting log. 164.528; 164.528(b)


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