Patient Information Policy
Use and Disclosure of Protected Health Information
to Persons Involved in the Patient’s Care and for
Notification Purposes
SCOPE:
All Louisiana State University (LSU) System health care
facilities and providers including, but not limited to
hospitals, physician practices, clinics, schools, etc. on
the LSU Health Sciences Center New Orleans Academic Campus.
Nota Bene: All LSU System health care facilities and
providers including, but not limited to hospitals, physician
clinics, schools, etc. on the LSU Health Sciences Center New
Orleans Academic Campus, are referred to in this policy as
LSUHSC-NO.
PURPOSE:
To provide guidance to the health care facilities and
providers affiliated with LSUHSC-NO on the requirements of
the Health Insurance Portability and Accountability Act,
Standards for Privacy of Individually Identifiable Health
Information (HIPAA Privacy Regulations), and any other
applicable state or Federal laws or regulations for
disclosing a patient’s Protected Health Information to a
family member, friend or other person identified by the
patient.
POLICY:
All LSUHSC-NO-affiliated health care facilities and
providers should provide a patient with an opportunity to
agree to or object to the disclosure of their Protected
Health Information to family members or other persons
identified by the patient, or for notification purposes.
DEFINITIONS:
Disclosure – For purposes of this policy, means the release,
transfer, or provision of access to PHI outside of LSUHSC-NO.
A disclosure of Protected Health Information may occur
orally or in writing.
Protected Health Information (sometimes referred to as
“PHI”) – For purposes of this policy means individually
identifiable health information, that relates to the past,
present or future health care services provided to an
individual. Examples of Protected Health Information include
medical and billing records of a patient.
Use - For purposes of this policy, means with respect to
Protected Health Information, the sharing, utilization, or
examination of Protected Health Information within and by
employees or agents of LSUHSC-NO.
PROCEDURE:
| 1.0 |
Uses and Disclosures of Protected Health
Information With the Patient Present |
| 1.1 |
If the individual is present and has the
capacity to make his or her own decisions,
LSUHSC-NO may disclose the PHI to a family member,
other relative, or a close personal friend of the
patient, or for notification purposes only if
LSUHSC-NO does one of the following:
- Obtains the individual’s agreement in each
encounter, orally or in writing, to disclose the
patient’s Protected Health Information to the
individual (e.g., family member, friend, other
person) that is present with the patient;
- Provides the individual with the opportunity
to object to such disclosure, and the individual
does not express an objection; or
- Reasonably infers from the circumstances,
based on the exercise of professional judgment
that the individual does not object to the
disclosure. Examples of when our LSUHSC-NO may
infer an individual’s agreement to disclose
Protected Health Information pursuant to this
option include, but are not limited to:
- when a patient brings a spouse into our
office when treatment is being discussed; or
- when a colleague or friend has brought the
individual to the emergency room for
treatment.
|
| 1.2 |
LSUHSC-NO is not required to verify the
identity of relatives or other individuals
involved in the individual’s care. The
individual’s act of involving the other persons in
his or her care is sufficient verification of
their identity. |
| 1.3 |
LSUHSC-NO must obtain the individual’s
agreement on every visit to our office as to
whether the Facility or Clinic may disclose the
individual’s Protected Health Information to a
relative or to another person assisting in the
individual’s care. |
| 1.4 |
LSUHSC-NO should not assume that an
individual’s agreement at one point in time to
disclose Protected Health Information to a
relative or friend applies to every visit to our
office. |
| 2.0 |
Uses and Disclosures of Protected Health
Information When the Patient is Not Present Or
Emergency Circumstances |
| 2.1 |
LSUHSC-NO may only make limited disclosures of
a patient’s Protected Health Information when the
patient is not present to be provided with an
opportunity to agree or object to a particular use
or disclosure of their Protected Health
Information. |
| 2.2 |
If the individual is not present, or the
opportunity to agree or object to the use or
disclosure cannot practicably be provided because
of the individual’s incapacity or an emergency
circumstance, LSUHSC-NO may, in the exercise of
professional judgment, determine whether the
disclosure is in the best interests of the
individual and, if so, disclose only the Protected
Health Information that is directly relevant to
the person’s involvement with the individual’s
health care. Examples of when employees of
LSUHSC-NO may use their professional judgment and
experience with common practice to make reasonable
inferences of the individual’s best interest in
allowing a person to act on behalf of the
individual include, but are not limited to:
- pick up filled prescriptions,
- medical supplies,
- X-rays, or
- other similar forms of PHI.
|
| 3.0 |
Use of Protected Health Information for
Notification Purposes |
| 3.1 |
LSUHSC-NO may use or disclose Protected Health
Information to notify, or assist in the
notification of (including identifying or
locating), a family member, a personal
representative of the individual, or another
person responsible for the care of the individual
of the individual’s location, general condition,
or death. Any such use or disclosure of Protected
Health Information for such notification purposes
must be in accordance with this policy. |
| 4.0 |
LSUHSC-NO may use or disclose Protected Health Information to a public or private entity authorized by law or by its charter to assist in disaster relief efforts, for the purposes of coordinating relief efforts, assistance in notification, or notification of (including identifying or locating) a family member, a personal representative of the individual, or another person responsible for the care of the individual, or the individual’s location, general condition, or death. |
REFERENCES:
45 C.F.R. § 164.510(b) |
