HIPAA Privacy Training for
Students:
A Self-Study Module
Matrix of
Developed by the
HIPAA Readiness Collaborative
June 2005
FACILITY NAME: Alcoholic Rehabilitation Services of Hawai‘i, dba Hina Mauka
|
SPECIAL CONSIDERATIONS
FOR PATIENT PRIVACY |
In addition to HIPAA, the strict confidentiality of
records of persons receiving alcohol and drug prevention and treatment
services is protected by Federal law, implemented through Federal regulations
42 C.F.R. (Code of Federal Regulations), Part 2. Noteworthy provisions: -
Prohibits disclosures except with client consent (or 9 other specific
conditions). -
Prohibits re-disclosure except with explicit signed
consent/authorization. This differs
from HIPAA. -
Allows limited disclosure for payment, evaluation, and other purposes
with Business Associate Agreements. |
|
FACILITY DIRECTORY ·
Patient Info Status ·
Callers or Visitors |
No directory is maintained for general/public
use. |
|
FACILITY DIRECTORY ·
Where is patient's information status
documented? |
Originals are found in the client clinical
record. Generally, unless a signed
consent/authorization to release information is found, we are not permitted
to contact family. Treatment Associates office maintains a directory of
clients and copies of signed consent/authorization for release of information
to specific persons making inquiry.
Reception desk, the usual first receiver of visitors and telephone
inquiries, is also provided with a copy of consent forms as applicable. |
|
FAMILY INVOLVEMENT ·
Where is patient's objection to
family involvement documented? |
In the client
clinical record. Generally, unless a
signed consent/authorization to release information is found, we are not
permitted to contact family. Also,
Reception Desk and Treatment Associate staff, who
are first receivers of visitors and telephone inquiries, are notified of
client’s objection through a memo from counselor or through daily census
meetings. |
|
OTHER RESTRICTION REQUESTS ·
Where is patient's restriction
request (and facility's decision) documented? |
In the client clinical record. Generally, unless a signed
consent/authorization to release information is found, we are not permitted
to contact family. Also, Treatment
Associate staff are notified through a memo from counselor
or through daily census meetings. |
|
FACIALLY DE-IDENTIFIED INFORMATION ·
Does facility permit use of facially
de-identified PHI for educational purposes? |
This information is not currently available. Information will be available to students
prior to their placement at Hina Mauka. |
|
ACCESS TO PHI ·
Whom should I contact if I need to
request access to PHI? |
Psychiatry residents may contact Medical Director,
program director or designee. R.N. or
any counselor may assist in locating PHI in the client record for any client
currently being seen by a psychiatry resident. For non-active cases, contact custodian of
records. |
|
REQUEST FOR PHI BY OTHER HEALTH CARE PROVIDERS FOR TREATMENT PURPOSES |
Signed consent/authorization by the client is
required. Consent must meet standards for 42 CFR, pt. 2. as
well as HIPAA. |
|
RESEARCH ·
Whom should I contact if I need more
information about requirements for research? |
Contact Hina Mauka’s Privacy Officer and IRB chair. |
|
ACCOUNTING OF DISCLOSURES ·
Who is responsible for accounting of
disclosures? Where and how are
disclosures documented? |
For disclosures from active clinical records, the
clinician making the disclosure records the fact in the client record. For
non-active clients, the custodian of records documents disclosures. Disclosures of financial information are
documented in a running record/log by staff making the disclosures. |
|
PRIVACY TRAINING REQUIREMENTS |
All staff are provided with Confidentiality and
Privacy Training, covering both 42 CFR, Part 2; and
HIPAA; upon hire or (for volunteers and students) job assignment. |
FACILITY NAME: Clinical Laboratories of
* Operates labs in following hospitals: Straub, both
Kapiolani Medical Centers, both
|
FACILITY DIRECTORY ·
Patient Info Status ·
Callers or Visitors |
N/a |
|
FACILITY DIRECTORY ·
Where is patient's information
status documented? |
N/a |
|
FAMILY INVOLVEMENT ·
Where is patient's objection to
family involvement documented? |
N/a |
|
OTHER RESTRICTION REQUESTS ·
Where is patient's restriction
request (and facility's decision) documented? |
Billing
Department |
|
FACIALLY DE-IDENTIFIED INFORMATION ·
Does facility permit use of facially
de-identified PHI for educational purposes? |
Yes |
|
ACCESS TO PHI ·
Whom should I contact if I need to
request access to PHI? |
Privacy Officer |
|
REQUEST FOR PHI BY OTHER HEALTH CARE PROVIDERS FOR TREATMENT PURPOSES |
Submit written
request stating purpose is treatment |
|
RESEARCH ·
Whom should I contact if I need more
information about requirements for research? |
Privacy Officer |
|
ACCOUNTING OF DISCLOSURES ·
Who is responsible for accounting of
disclosures? Where and how are
disclosures documented? |
Privacy Officer |
|
PRIVACY TRAINING REQUIREMENTS |
Will accept HRC
training for residents |
FACILITY NAME: Diagnostic Laboratory Services, Inc. (DLS)
|
FACILITY DIRECTORY ·
Patient Info Status ·
Callers or Visitors |
N/A N/A |
|
FACILITY DIRECTORY ·
Where is patient's information
status documented? |
N/A |
|
FAMILY INVOLVEMENT ·
Where is patient's objection to
family involvement documented? |
N/A |
|
OTHER RESTRICTION REQUESTS ·
Where is patient's restriction
request (and facility's decision) documented? |
“Restriction
Request Forms” and their disposition maintained by the DLS Privacy Officer. |
|
FACIALLY DE-IDENTIFIED INFORMATION ·
Does facility permit use of facially
de-identified PHI for educational purposes? |
Yes, check with
DLS Privacy Officer. |
|
ACCESS TO PHI ·
Whom should I contact if I need to
request access to PHI? |
DLS Privacy
Officer. |
|
REQUEST FOR PHI BY OTHER HEALTH CARE PROVIDERS FOR TREATMENT PURPOSES |
DLS
will release PHI to other providers for treatment purposes after verifying
the identity of the requestor and the authority to receive PHI. |
|
RESEARCH ·
Whom should I contact if I need more
information about requirements for research? |
DLS Privacy
Officer. |
|
ACCOUNTING OF DISCLOSURES ·
Who is responsible for accounting of
disclosures? Where and how are
disclosures documented? |
Automated
computerized accounting for most disclosures (DOH). Manual (Ad Hoc) accounting for others
(subpoenas etc.) Computerized
tracking and documentation accessible by Privacy Officer. |
|
PRIVACY TRAINING REQUIREMENTS |
DLS
accepts HRC’s standardized community Training Program. |
FACILITY NAME:
|
SPECIAL CONSIDERATIONS FOR PATIENT PRIVACY |
HSH IS A
PSYCHIATRIC FACILITY AND IS REQUIRED TO COMPLY WITH SPECIFIC JCAHO, DOJ, AND
DOH REQUIREMENTS. |
|
FACILITY DIRECTORY ·
Patient Info Status ·
Callers or Visitors |
IN PATIENT
CHART TELECOMMUNICATIONS |
|
FACILITY DIRECTORY ·
Where is patient's information
status documented? |
IN PATIENT
CHART |
|
FAMILY INVOLVEMENT ·
Where is patient's objection to
family involvement documented? |
IN PATIENT
CHART |
|
OTHER RESTRICTION REQUESTS ·
Where is patient's restriction
request (and facility's decision) documented? |
IN PATIENT
CHART |
|
FACIALLY DE-IDENTIFIED INFORMATION ·
Does facility permit use of facially
de-identified PHI for educational purposes? |
YES |
|
ACCESS TO PHI ·
Whom should I contact if I need to
request access to PHI? |
CAROLYN
TAKAHASHI, ACTING CHIEF OF MEDICAL RECORDS |
|
REQUEST FOR PHI BY OTHER HEALTH CARE PROVIDERS FOR TREATMENT PURPOSES |
MEDICAL RECORDS |
|
RESEARCH ·
Whom should I contact if I need more
information about requirements for research? |
RYAN MCMULLIN,
PH.D. |
|
ACCOUNTING OF DISCLOSURES ·
Who is responsible for accounting of
disclosures? Where and how are
disclosures documented? |
ALL PATIENT
CARE STAFF IN PATIENT
CHART |
|
PRIVACY TRAINING REQUIREMENTS |
FILM IN STAFF
DEVELOPMENT |
|
OTHER |
PRIVACY OFFICER
IS RUTH STEWAT, RN, MS, CPHQ, CHIEF OF STANDARDS AND COMPLIANCE |
FACILITY NAME:
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FACILITY DIRECTORY ·
Patient Info Status ·
Callers or Visitors |
1.
Regular information—location only. 2.
No information. Condition is
given by nursing staff only. |
|
FACILITY DIRECTORY ·
Where is patient's information
status documented? |
Hospital
Information System (McKesson) and on the Consent to Release to the Public
form in the patient’s record. |
|
FAMILY INVOLVEMENT ·
Where is patient's objection to
family involvement documented? |
Release is
permitted unless the patient has completed a Request for Restriction form. |
|
OTHER RESTRICTION REQUESTS ·
Where is patient's restriction
request (and facility's decision) documented? |
On the Request
for Restriction form in the patient’s medical record. |
|
FACIALLY DE-IDENTIFIED INFORMATION ·
Does facility permit use of facially
de-identified PHI for educational purposes? |
Yes |
|
ACCESS TO PHI ·
Whom should I contact if I need to
request access to PHI? |
Medical Records
Department |
|
REQUEST FOR PHI BY OTHER HEALTH CARE PROVIDERS FOR TREATMENT PURPOSES |