HIPAA Privacy Training for Students:

A Self-Study Module

Matrix of

Hawaii Health Care Providers

Download PDF Version (112k)

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 Hawaii* & Pan Pacific Pathologists*

* Operates labs in following hospitals: Straub, both Kapiolani Medical Centers, both St. Francis Hospitals, Maui Memorial Hospital, Hilo Medical Center, Kona Community Hospital, North Hawaii Community Hospital, & Wilcox Hospital

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:  HAWAII STATE HOSPITAL

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:  Hilo Medical Center

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	Medical Records Department
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?	Medical Records Department
PRIVACY TRAINING REQUIREMENTS	Record of completion of HIPAA training.

FACILITY NAME:  Kapiolani Medical Center at Pali Momi

FACILITY DIRECTORY · Patient Info Status · Callers or Visitors	STATUS: 1. Regular info 2. No info
FACILITY DIRECTORY · Where is patient's information status documented?	Hospital Information systems: SMS
FAMILY INVOLVEMENT · Where is patient's objection to family involvement documented?	Release okay unless patient has made specific objections.  Would be documented in the medical record
OTHER RESTRICTION REQUESTS · Where is patient's restriction request (and facility's decision) documented?	Restriction Request form in the medical record
FACIALLY DE-IDENTIFIED INFORMATION · Does facility permit use of facially de-identified PHI for educational purposes?	Yes – refer to Policy regarding Educational Uses of PHI
ACCESS TO PHI · Whom should I contact if I need to request access to PHI?	Medical Records for medical information; Business Services for billing records; Medical Records, ORSOS system administrators for data reports Note:  Data Access Request form Required
REQUEST FOR PHI BY OTHER HEALTH CARE PROVIDERS FOR TREATMENT PURPOSES	PHI may be released for treatment purposes in response to any of the following 1. Patient authorization 2. Letter from physician practice, 3. Provider Request for Information form or similar document
RESEARCH · Whom should I contact if I need more information about requirements for research?	IRB or Privacy Officer
ACCOUNTING OF DISCLOSURES · Who is responsible for accounting of disclosures? · Where and how are disclosures documented?	· Each individual is responsible for documenting disclosures. All documentation is kept in the chart.  · Documentation forms are available on each unit.  Check with Supervisor of area to see what their procedure is. Centralized Collection points:  1. Medical Records for Medical records; 2. Business services for billing records
PRIVACY TRAINING REQUIREMENTS	Completion of HPH HIPAA training requirements for direct access or  HRC’s standardized community Training Program
OTHER	Contact Privacy Officer

FACILITY NAME:  Kapiolani Medical Center for Women & Children

FACILITY DIRECTORY · Patient Info Status · Callers or Visitors	STATUS: 1. Regular info 2. No info
FACILITY DIRECTORY · Where is patient's information status documented?	Hospital Information systems: SMS and Karelink
FAMILY INVOLVEMENT · Where is patient's objection to family involvement documented?	Release okay unless patient has made specific objections.  Would be documented in the medical record
OTHER RESTRICTION REQUESTS · Where is patient's restriction request (and facility's decision) documented?	Restriction Request form in the medical record
FACIALLY DE-IDENTIFIED INFORMATION · Does facility permit use of facially de-identified PHI for educational purposes?	Yes – refer to Policy regarding Educational Uses of PHI
ACCESS TO PHI · Whom should I contact if I need to request access to PHI?	Medical Records for medical information; Business Services for billing records; Medical Records, Karelink or ORSOS system administrators for data reports Note:  Data Access Request form Required
REQUEST FOR PHI BY OTHER HEALTH CARE PROVIDERS FOR TREATMENT PURPOSES	PHI may be released for treatment purposes in response to any of the following 1. Patient authorization 2. Letter from physician practice, 3. Provider Request for Information form or similar document
RESEARCH · Whom should I contact if I need more information about requirements for research?	IRB or Privacy Officer
ACCOUNTING OF DISCLOSURES · Who is responsible for accounting of disclosures? · Where and how are disclosures documented?	· Each individual is responsible for documenting disclosures. All documentation is kept in the chart.  · Documentation forms are available on each unit.  Check with Supervisor of area to see what their procedure is. Centralized Collection points:  1. Medical Records for Medical records; 2. Business services for billing records
PRIVACY TRAINING REQUIREMENTS	Completion of HPH HIPAA training requirements for direct access or  HRC’s standardized community Training Program
OTHER	Contact Privacy Officer

FACILITY NAME:  Kuakini Health System

SPECIAL CONSIDERATIONS FOR PATIENT PRIVACY	This response applies to acute care and long term care inpatients. Patient privacy issues are discussed at registration and special requests are flagged in the computer system.
FACILITY DIRECTORY · Patient Info Status · Callers or Visitors	This response applies to acute care and long term care inpatients. Patient privacy issues are discussed at registration and special requests are flagged in the computer system.  If the patient request that they not be included in the facility directory, their request is flagged in the computer and forwarded to the receiving floor.  The hospital operator will not have that patient’s name on the directory at all.
FACILITY DIRECTORY · Where is patient's information status documented?	This response applies to acute care and long term care inpatients. Patient privacy issues are discussed at registration and special requests are flagged in the computer system.  If the patient request that they not be included in the facility directory, their request is flagged in the computer and forwarded to the receiving floor.  The hospital operator will not have that patient’s name on the directory at all.
FAMILY INVOLVEMENT · Where is patient's objection to family involvement documented?	This response applies to acute care and long term care inpatients.  Patient privacy issues, including the identification of a PRIMARY individual to disclose protected health information are discussion during registration.  The information gleaned is flagged in the computer system.
OTHER RESTRICTION REQUESTS · Where is patient's restriction request (and facility's decision) documented?	This response applies to acute care and long term care inpatients. Patient privacy issues are discussed at registration and special requests are flagged in the computer system.
FACIALLY DE-IDENTIFIED INFORMATION · Does facility permit use of facially de-identified PHI for educational purposes?	Yes for both acute care and long term care inpatient within specified guidelines.
ACCESS TO PHI · Whom should I contact if I need to request access to PHI?	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?	Robin Miyamoto, Research Coordinator
ACCOUNTING OF DISCLOSURES · Who is responsible for accounting of disclosures?  Where and how are disclosures documented?	Medical Records Tracked by the computer system.
PRIVACY TRAINING REQUIREMENTS	Record of education on HIPAA. Signature on the Confidentiality form.

FACILITY NAME: KULA Hospital

FACILITY DIRECTORY · Patient Info Status · Callers or Visitors	Front Desk Each Nurses Station
FACILITY DIRECTORY · Where is patient's information status documented?	Front Desk Medical Record
FAMILY INVOLVEMENT · Where is patient's objection to family involvement documented?	Medical Record
OTHER RESTRICTION REQUESTS · Where is patient's restriction request (and facility's decision) documented?	Front Desk Medical Records
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
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?	Medical Records
ACCOUNTING OF DISCLOSURES · Who is responsible for accounting of disclosures?  Where and how are disclosures documented?	Medical Records
PRIVACY TRAINING REQUIREMENTS	HRC Privacy Training & Signed Confidentiality Agreement

FACILITY NAME:  Leahi Hospital

SPECIAL CONSIDERATIONS FOR PATIENT PRIVACY	Long term care and acute TB unit
FACILITY DIRECTORY · Patient Info Status · Callers or Visitors	Regular No Information Noted in chart, computer system, internal directory
FACILITY DIRECTORY · Where is patient's information status documented?	Noted in chart, computer system, internal directory
FAMILY INVOLVEMENT · Where is patient's objection to family involvement documented?	Noted in chart, computer system, internal directory
OTHER RESTRICTION REQUESTS · Where is patient's restriction request (and facility's decision) documented?	Noted in chart, computer system, internal directory
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
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?	HIPAA Officer- Administration
ACCOUNTING OF DISCLOSURES · Who is responsible for accounting of disclosures?  Where and how are disclosures documented?	Medical Records
PRIVACY TRAINING REQUIREMENTS	HRC Privacy Training & Signed Confidentiality Agreement

FACILITY NAME:  The Queen’s Medical Center (QMC)

FACILITY DIRECTORY · Patient Info Status · Callers or Visitors	1. Regular info- location and condition 2. Limited info – acknowledge patient is at QMC only 3. No info 4. Pending- Trauma/VIP pt.  No info to public while trying to notify family and determine status
FACILITY DIRECTORY · Where is patient's information status documented?	Hospital Information System (SMS) Patient Care Summary
FAMILY INVOLVEMENT · Where is patient's objection to family involvement documented?	Release okay unless patient has made specific objections.  Would be documented in the medical record
OTHER RESTRICTION REQUESTS · Where is patient's restriction request (and facility's decision) documented?	Refer patient to the Privacy Officer
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 for charts and copies - IS help desk for access to computer systems - Data Coordinator of system for data queries and reports
REQUEST FOR PHI BY OTHER HEALTH CARE PROVIDERS FOR TREATMENT PURPOSES	- Okay to release if treatment relationship documented - If not documented, Licensed health care provider (MD or RN) will accept  patient authorization, letter from physician practice, Provider Request Form
RESEARCH · Whom should I contact if I need more information about requirements for research?	QMC Research Regulatory Office at 808-547-4512
ACCOUNTING OF DISCLOSURES · Who is responsible for accounting of disclosures?  Where and how are disclosures documented?	Through computerized computer entry system – CLiQ
PRIVACY TRAINING REQUIREMENTS	Satisfactory completion of Collaborative’s Privacy Training Session
OTHER	Students may not remove documents containing PHI from facility.  See Privacy Officer for approval and de-identification.

FACILITY NAME:   Rehabilitation Hospital of the Pacific (REHAB)

FACILITY DIRECTORY · Patient Info Status · Callers or Visitors	Regular information No information (NOI)
FACILITY DIRECTORY · Where is patient's information status documented?	Hospital information system (Affinity) Medical record chart cover :  NOI sticker
FAMILY INVOLVEMENT · Where is patient's objection to family involvement documented?	Family contacts listed on Face Sheet Objections are recorded in chart:  Discharge Plan Screening form in Case Management section
OTHER RESTRICTION REQUESTS · Where is patient's restriction request (and facility's decision) documented?	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?	For medical record: Clinical Information Dept (CID) For electronic access:  Information Systems Dept (IS)
REQUEST FOR PHI BY OTHER HEALTH CARE PROVIDERS FOR TREATMENT PURPOSES	May release for treatment after verification of requesting provider’s involvement in patient’s care (verification form)
RESEARCH · Whom should I contact if I need more information about requirements for research?	Research, Education, and Training Dept (RET)
ACCOUNTING OF DISCLOSURES · Who is responsible for accounting of disclosures?  Where and how are disclosures documented?	Clinical Information Dept (CID) Disclosures are documented in the medical record by person making the disclosure
PRIVACY TRAINING REQUIREMENTS	Either REHAB privacy orientation or HRC Privacy Training

FACILITY NAMES:  St. Francis Medical Center & St. Francis Medical Center-West

FACILITY DIRECTORY · Patient Info Status · Callers or Visitors	1. Regular Information 2. No Information
FACILITY DIRECTORY · Where is patient's information status documented?	Hospital information system (SMS). Confidential" header on patient's Face Sheet.  Direct visitors to Information Desk or Operator who will check the Secure Census.
FAMILY INVOLVEMENT · Where is patient's objection to family involvement documented?	Permissible unless patient has requested to restrict family involvement.  Patient's request and facility decision are documented on the Restriction Request form in the medical record.
OTHER RESTRICTION REQUESTS · Where is patient's restriction request (and facility's decision) documented?	Restriction Request form in the 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?	Health Information Management department for medical records Business Office for billing records Information Services Help Desk for data queries or reports
REQUEST FOR PHI BY OTHER HEALTH CARE PROVIDERS FOR TREATMENT PURPOSES	Permissible if treatment relationship is documented within hospital information system, or with patient authorization, Provider Request form, or fax / letter from other healthcare provider.
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?	Each program, service, department or facility is responsible for documenting disclosures, and making such documentation available to the Privacy Officer upon request.
PRIVACY TRAINING REQUIREMENTS	Satisfactory completion of HRC or SFHS privacy training program
OTHER	Procedures are similar for St. Francis Hospice and St. Francis Home Care Services

FACILITY NAME: Straub Clinic and Hospital

FACILITY DIRECTORY · Patient Info Status · Callers or Visitors	STATUS: Regular info No info VIP (CE executives, CE BOD, celebrities, etc.)
FACILITY DIRECTORY · Where is patient's information status documented?	Hospital Information system - IDX
FAMILY INVOLVEMENT · Where is patient's objection to family involvement documented?	Release okay unless patient has made specific objections.  Would be documented in the medical record
OTHER RESTRICTION REQUESTS · Where is patient's restriction request (and facility's decision) documented?	Restriction Request form in the 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 for medical information; Business Services for billing records IT for reports Note:  Data Access Request form Required if not for TPO
REQUEST FOR PHI BY OTHER HEALTH CARE PROVIDERS FOR TREATMENT PURPOSES	Patient authorization Letter from physician practice, Provider Request for Information form or similar document
RESEARCH · Whom should I contact if I need more information about requirements for research?	IRB or Privacy Officer
ACCOUNTING OF DISCLOSURES · Who is responsible for accounting of disclosures?  Where and how are disclosures documented?	Centralized Collection points:  Medical Records for Medical records; Business services for billing records Each individual is responsible for documenting disclosures. All documentation is kept in the chart.  Each area has different approach.  Check with Supervisor of area to see what their procedure is.
PRIVACY TRAINING REQUIREMENTS	Completion of HPH HIPAA training requirements for direct access or  HRC’s standardized community Training Program
OTHER	Plastic Surgery Records kept separate from Medical Records; See Privacy Officer

FACILITY NAME:  Wahiawa General Hospital

FACILITY DIRECTORY · Patient Info Status · Callers or Visitors	1. Regular info 2. No info
FACILITY DIRECTORY · Where is patient's information status documented?	No info patients have a plus sign (+) noted to the right of their names on the CPSI information system.
FAMILY INVOLVEMENT · Where is patient's objection to family involvement documented?	Persons whom staff may contact and/or speak with are listed on the Face Sheet.
OTHER RESTRICTION REQUESTS · Where is patient's restriction request (and facility's decision) documented?	Request for Restriction form
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	Patient authorization is required.
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 TRAINING REQUIREMENTS