Basic Principle. Required Disclosures. A covered entity must disclose protected health information in only two situations: a to individuals or their personal representatives specifically when they request access to, or an accounting of disclosures of, their protected health information; and b to HHS when it is undertaking a compliance investigation or review or enforcement action.
A covered entity may disclose protected health information to the individual who is the subject of the information. A covered entity may use and disclose protected health information for its own treatment, payment, and health care operations activities. Treatment is the provision, coordination, or management of health care and related services for an individual by one or more health care providers, including consultation between providers regarding a patient and referral of a patient by one provider to another.
Payment encompasses activities of a health plan to obtain premiums, determine or fulfill responsibilities for coverage and provision of benefits, and furnish or obtain reimbursement for health care delivered to an individual 21 and activities of a health care provider to obtain payment or be reimbursed for the provision of health care to an individual.
Health care operations are any of the following activities: a quality assessment and improvement activities, including case management and care coordination; b competency assurance activities, including provider or health plan performance evaluation, credentialing, and accreditation; c conducting or arranging for medical reviews, audits, or legal services, including fraud and abuse detection and compliance programs; d specified insurance functions, such as underwriting, risk rating, and reinsuring risk; e business planning, development, management, and administration; and f business management and general administrative activities of the entity, including but not limited to: de-identifying protected health information, creating a limited data set, and certain fundraising for the benefit of the covered entity.
Most uses and disclosures of psychotherapy notes for treatment, payment, and health care operations purposes require an authorization as described below. Informal permission may be obtained by asking the individual outright, or by circumstances that clearly give the individual the opportunity to agree, acquiesce, or object. Where the individual is incapacitated, in an emergency situation, or not available, covered entities generally may make such uses and disclosures, if in the exercise of their professional judgment, the use or disclosure is determined to be in the best interests of the individual.
Facility Directories. It is a common practice in many health care facilities, such as hospitals, to maintain a directory of patient contact information. Members of the clergy are not required to ask for the individual by name when inquiring about patient religious affiliation. For Notification and Other Purposes. In addition, protected health information may be disclosed for notification purposes to public or private entities authorized by law or charter to assist in disaster relief efforts.
The Privacy Rule does not require that every risk of an incidental use or disclosure of protected health information be eliminated. Specific conditions or limitations apply to each public interest purpose, striking the balance between the individual privacy interest and the public interest need for this information.
Required by Law. Covered entities may use and disclose protected health information without individual authorization as required by law including by statute, regulation, or court orders. Public Health Activities. Victims of Abuse, Neglect or Domestic Violence. In certain circumstances, covered entities may disclose protected health information to appropriate government authorities regarding victims of abuse, neglect, or domestic violence. Health Oversight Activities.
Covered entities may disclose protected health information to health oversight agencies as defined in the Rule for purposes of legally authorized health oversight activities, such as audits and investigations necessary for oversight of the health care system and government benefit programs. Judicial and Administrative Proceedings. Covered entities may disclose protected health information in a judicial or administrative proceeding if the request for the information is through an order from a court or administrative tribunal.
Such information may also be disclosed in response to a subpoena or other lawful process if certain assurances regarding notice to the individual or a protective order are provided. Law Enforcement Purposes. Covered entities may disclose protected health information to funeral directors as needed, and to coroners or medical examiners to identify a deceased person, determine the cause of death, and perform other functions authorized by law.
Cadaveric Organ, Eye, or Tissue Donation. Covered entities may use or disclose protected health information to facilitate the donation and transplantation of cadaveric organs, eyes, and tissue.
Serious Threat to Health or Safety. Covered entities may disclose protected health information that they believe is necessary to prevent or lessen a serious and imminent threat to a person or the public, when such disclosure is made to someone they believe can prevent or lessen the threat including the target of the threat. Covered entities may also disclose to law enforcement if the information is needed to identify or apprehend an escapee or violent criminal.
Essential Government Functions. An authorization is not required to use or disclose protected health information for certain essential government functions.
Such functions include: assuring proper execution of a military mission, conducting intelligence and national security activities that are authorized by law, providing protective services to the President, making medical suitability determinations for U. State Department employees, protecting the health and safety of inmates or employees in a correctional institution, and determining eligibility for or conducting enrollment in certain government benefit programs.
A limited data set is protected health information from which certain specified direct identifiers of individuals and their relatives, household members, and employers have been removed. An authorization must be written in specific terms. It may allow use and disclosure of protected health information by the covered entity seeking the authorization, or by a third party.
All authorizations must be in plain language, and contain specific information regarding the information to be disclosed or used, the person s disclosing and receiving the information, expiration, right to revoke in writing, and other data. The Privacy Rule contains transition provisions applicable to authorizations and other express legal permissions obtained prior to April 14, Psychotherapy Notes Marketing is any communication about a product or service that encourages recipients to purchase or use the product or service.
Marketing also is an arrangement between a covered entity and any other entity whereby the covered entity discloses protected health information, in exchange for direct or indirect remuneration, for the other entity to communicate about its own products or services encouraging the use or purchase of those products or services. No authorization is needed, however, to make a communication that falls within one of the exceptions to the marketing definition.
See additional guidance on Marketing. Minimum Necessary. A covered entity must make reasonable efforts to use, disclose, and request only the minimum amount of protected health information needed to accomplish the intended purpose of the use, disclosure, or request.
When the minimum necessary standard applies to a use or disclosure, a covered entity may not use, disclose, or request the entire medical record for a particular purpose, unless it can specifically justify the whole record as the amount reasonably needed for the purpose.
See additional guidance on Minimum Necessary. Access and Uses. For internal uses, a covered entity must develop and implement policies and procedures that restrict access and uses of protected health information based on the specific roles of the members of their workforce.
These policies and procedures must identify the persons, or classes of persons, in the workforce who need access to protected health information to carry out their duties, the categories of protected health information to which access is needed, and any conditions under which they need the information to do their jobs.
Disclosures and Requests for Disclosures. Covered entities must establish and implement policies and procedures which may be standard protocols for routine, recurring disclosures, or requests for disclosures , that limits the protected health information disclosed to that which is the minimum amount reasonably necessary to achieve the purpose of the disclosure.
Individual review of each disclosure is not required. For non-routine, non-recurring disclosures, or requests for disclosures that it makes, covered entities must develop criteria designed to limit disclosures to the information reasonably necessary to accomplish the purpose of the disclosure and review each of these requests individually in accordance with the established criteria.
Reasonable Reliance. If another covered entity makes a request for protected health information, a covered entity may rely, if reasonable under the circumstances, on the request as complying with this minimum necessary standard. Privacy Practices Notice. Each covered entity, with certain exceptions, must provide a notice of its privacy practices.
The notice must describe the ways in which the covered entity may use and disclose protected health information. The notice must include a point of contact for further information and for making complaints to the covered entity. Covered entities must act in accordance with their notices. The Rule also contains specific distribution requirements for direct treatment providers, all other health care providers, and health plans. See additional guidance on Notice. Covered entities, whether direct treatment providers or indirect treatment providers such as laboratories or health plans must supply notice to anyone on request.
The covered entities in an organized health care arrangement may use a joint privacy practices notice, as long as each agrees to abide by the notice content with respect to the protected health information created or received in connection with participation in the arrangement.
A health plan must distribute its privacy practices notice to each of its enrollees by its Privacy Rule compliance date. The Rule also gives patients rights over their health information, including rights to examine and obtain a copy of their health records, and to request corrections.
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