CM-53 - HIPAA Privacy Policies

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) (P. L. 104-191) is an amendment to the Social Security Act. Its primary purpose is to place restrictions on what can be categorized as pre-existing conditions when an employee moves from one job to another. However, Title II of the Act, entitled Administrative Simplification, sets new requirements for healthcare providers, payers and clearinghouses in the areas of privacy, information security, and electronic data interchange. In accordance with these requirements, the following LSUHSC privacy policies have been enacted.

1. Privacy Notice Policy: Notice of Privacy Practices Policy
   • Attachment A: Notice of Privacy Practices for Protected Health Information
   • Attachment B: Notice of Privacy Practices for Protected Health Information (Spanish version)
   • Attachment C: Acknowledgement of Receipt of Notice of Privacy Practices
2. Patient Information Policy: Privacy Official and Complaint Contact
3. Patient Information Policy: Accounting of Disclosures of Protected Health Information
   • Attachment A: Accounting of Disclosures of Protected Health Information
   • Attachment B: Accounting of Disclosures of Protected Health Information for Research
   • Attachment C: Tracking Form for Disclosure of Protected Health Information
4. Minimum Necessary Policy: Minimum Necessary Uses and Disclosures of Protected Health Information
5. Patient Information Policy: Whistleblower/Non-Retaliation
6. Mitigation Policy: Breach Mitigation and Notification Policy
7. Patient Information Policy: Training and Education Requirements for Members of the LSU System Facility Workforce
   • Attachment A: Confidentiality Agreement
8. Documentation Policy: Documentation Requirements
9. Restriction Policy: Patient's Request for Restriction of Uses and Disclosures of Their Protected Health Information
10. Patient Information Policy: Patient's Right of Access to and Obtain a Copy of their Protected Health Information
    • Attachment A: Patient’s Request for Access to and to Obtain a Copy of Their Protected Health Information
11. Patient Information Policy: Patient's Right to Request an Amendment to their Protected Health Information
    • Attachment A: Sample letter to Patient for Approved Amendments
    • Attachment B: Sample Letter to Notify Other Entities of Amendment
    • Attachment C: Sample Letter to Notify Individual’s of a Delay in Their Amendment Request
    • Attachment D: Patient Request for Amendment of Protected Health Information
    • Attachment E: Sample Letter to Patient Re: Denial Requests for Amendment
12. Patient Information Policy: Patient's Right to Request and to Receive Confidential Communications by Alternative Means or at Alternative Locations
    • Attachment A: Request to Receive Confidential Information by Alternative Means or Alternative Locations
13. Patient Information Policy: Safeguards
14. Patient Information Policy: Limited Data Set
    • Attachment A: Limited Data Set Request and Data Use Agreement
15. Patient Information Policy: De-Identification of Protected Health Information
    • Attachment A: Request for De-Identified Information
16. Treatment Payment Operations Policy: Use and Disclosure of Protected Health Information for Payment, Treatment and Health Care Operations
17. Patient Information Policy: Use and Disclosure of Protected Health Information for Facility Directory Purposes
    • Attachment A: Permission to Use and Disclose Protected Health Information for LSUHSC-NO Facility Directory
18. Patient Information Policy: Use and Disclosure of Protected Health Information for Marketing Purposes
    • Attachment A: Media Release Form
    • Attachment B: Authorization for Use and Disclosure of Protected Health Information for Media* Purposes
    • Attachment C: Authorization for Use and Disclosure of Protected Health Information for Media* Purposes (Spanish version)
19. Human Subject /Patient Policy: Use and Disclosure of Protected Health Information for Research
    • Attachment A1: Authorization for Use and Disclosure of Protected Health Information for Research Purposes (with HIV/Substance Abuse language)
    • Attachment A2: Authorization for Use and Disclosure of Protected Health Information for Research Purposes (without HIV/Substance Abuse language)
    • Attachment B: Principal Investigator’s Certification of Requisition for Research on Decedent’s Information
    • Attachment C: Principal Investigator’s Certification of Review of Data Collection for Reviews Preparatory to Research
    • Attachment D: Principal’s Investigators De-Identification Form for Approved Exempt Research
    • Attachment E: Authorization for Use and Disclosure of Protected Health Information for Research Purposes — Stanley S. Scott Cancer Center
20. Patient Information Policy: Use or Disclosure of Protected Health Information That Require an Individual's Written Authorization
    • Attachment A: To Authorization Policy
    • Attachment B: Authorization for Release of Protected Health Information Patient Identification
    • Attachment C: Authorization for Release of Protected Health Information Patient Identification (Spanish version)
21. Patient Information Policy: Use and Disclosure of Protected Health Information to Persons Involved in the Patient's Care and For Notification Purposes
22. Patient Information Policy: Use and Disclosure of Protected Health Information to Business Associates
    • Attachment A: Business Associate Contract Addendum
23. Patient Information Policy: Use and Disclosure of Protected Health Information for Fundraising
24. Discipline Policy: Employee Conduct and Disciplinary Sanctions