PRIVACY POLICY AND PROCEDURES	Policy #: 2100.3
LSU Health Sciences Center New Orleans Date Effective: April 14, 2003	Table of Contents

Patient Information Policy

Accounting of Disclosures of Protected Health Information

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 a patient’s right to request an accounting of the uses and disclosures of their Protected Health Information, as required by 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.

POLICY:

All LSUHSC-NO health care facilities and providers must provide patients with a right to request and receive an accounting of the uses and disclosures of their Protected Health Information by any LSUHSC-NO health care facility or health care provider. The provider must designate the area in which this accounting information will be available.

DEFINITIONS:

Protected Health Information (sometime 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.

Privacy Officer – person designated by LSUHSC-NO as the Privacy Officer.

Disclosure or Release – The release, transfer, provision of access to, or divulging of information in any other manner outside LSUHSC-NO. The words “disclosure” and “release” have the same meaning for purposes of this policy.

PROCEDURE:

1.0

Rights of a Patient to an Accounting. A patient has the right to receive an accounting of the disclosures of Protected Health Information made by LSUHSC-NO for up to six (6) years prior to the date on which the accounting is requested, except for the following disclosures:

To carry out treatment, payment and health care operations;
To individuals of Protected Health Information about them;
Incident to another permissible or required use or disclosure of PHI (e.g. overheard conversations)
Pursuant to a valid HIPAA authorization;
For a hospital’s or health care facilities’ directory;
To persons involved in the patient’s care;
For national security or intelligence purposes;
For notification purposes such as identifying or locating a family member, or personal representative to inform them of the patient’s location, general condition or death;
To correctional institutions or law enforcement officials as allowed in the HIPAA Privacy Regulations;
As part of a limited data set;.
If the Protected Health Information was disclosed prior to the HIPAA compliance date, of April 14, 2003.
Pursuant to and in compliance with a valid HIPAA authorization to disclose psychotherapy notes or PHI for marketing;

2.0

Suspension of Accounting.

2.1

Written Suspension:
LSUHSC-NO must temporarily suspend a patient’s right to receive an accounting of disclosures to a health oversight agency or law enforcement official, for the time specified by such agency or official, if such agency or official provides LSUHSC-NO with a written statement that such an accounting to the individual would be reasonably likely to impede the agency’s activities and specifying the time for which such a suspension is required .

2.2

Oral Suspension:
If LSUHSC-NO should receive the request orally, the Privacy Officer should:

Document the statement, including the identity of the agency or official making the statement
Temporarily suspend the individual’s right to an accounting of disclosures subject to the statement
Limit the temporary suspension to no longer than 30 days from the date of the oral statement, unless a written statement is submitted during that time.

3.0

Content of the Accounting. The content of the accounting must be in writing and unless specific for a shorter time period, cover six (6) years prior to the date of the request, including to or by business associates of LSUHSC-NO. The accounting must include for each disclosure the following:

The date of the disclosure;
The name of the entity or person who receive the PHI, and if known, the address of such entity or person;
A brief description of the PHI disclosed; and
A brief statement of the purpose of the disclosure that reasonably informs the patient of their personal representative of the basis for the disclosure or, in lieu of such statement, a copy of the written request for disclosure, if any.

4.0	Multiple Disclosures. If, during the period covered by the accounting, LSUHSC-NO has made multiple disclosures or PHI to the same person or entity for a single purpose, the accounting may, with respect to such multiple disclosures, provide: The information listed in 3.0; The frequency, periodicity, or number of the disclosures made during the accounting period; and The date of the last such disclosure during the accounting period.
5.0	Research Disclosures. If, during the period covered by the accounting, LSUHSC-NO has made disclosures of PHI for a particular research purpose in accordance with 45 CFR 164.512 (i) for 50 or more individuals, the accounting may, with respect to such disclosures for which the PHI about the individual may have been included, provide: The name of the protocol other research activity; A plain language description of the research protocol or other research activity, including the purpose of the research and t he criteria for selecting particular records; A brief description of the type of PHI that was disclosed; The date or period of time during which such disclosures occurred, or may have occurred, including the date of the last such disclosure during the accounting period; The name, address and telephone number of the entity that sponsored the research and of the researcher to whom the information was disclosed; and A statement that the PHI of the patient may or may not have been disclosed for a particular protocol or other research activity. If LSUHSC-NO provides an accounting for research disclosures and if it is reasonably likely that PHI of the patient was disclosed for such research protocol or activity, LSUHSC-NO shall, at the request of the patient assist in contacting the entity that sponsored the research and the researcher.
6.0	Time Period for Responding to Accounting Requests. LSUHSC-NO shall provide the patient the requested accounting within 60 days from the date of receipt of such request or if LSUHSC-NO is unable to provide the accounting within this time frame they shall provide a written statement of the reasons for the delay and the date by which LSUHSC-NO shall provide the accounting. LSUHSC-NO can have only one such extension of time and can be no more than 30 days.
7.0	Fees for Second Accounting in Same Calendar Year. LSUHSC-NO must provide the first accounting to an individual in any 12 month period without charge. LSUHSC-NO may impose a reasonable, cost-based fee for each subsequent request for an accounting by the same individual within the 12 month period, provided that LSUHSC-NO inform the patient in advance of the fee and provide the patient with an opportunity to withdraw or modify the request for a subsequent accounting in order to avoid or reduce the fee.

REFERENCE:

45 C.F.R. § 164.528