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HIPAA Accounting of Disclosures of Protected Health Information Sample
(selected via the [Patient Demographic] button)
PCM users only
This sample shows the content displayed in the web browser when the [Update] button is selected in the email. After the patient selects [Submit] the completed form is filed in the patient’s PCM chart.
HIPAA/PRIVACY
Accounting of Disclosures of Protected Health Information
Pt Name:LASTNAME, FIRSTNAME Date:08-Apr-2019
PURPOSE
Patients have the right to receive an accounting of the disclosures of their Protected Health Information
(PHI) maintained in their Designated Record Set. The following is the process for responding to a
patient's request for an accounting of disclosures of their PHI made by the Facility.
POLICY
Each patient may request and receive an accounting of trackable disclosures of PHI made by the Facility.
The potential areas where accounting of disclosures applies are listed in the Notice of Privacy Practices.
The Facility will provide such an accounting, in accordance with the HIPAA Privacy Rule, when requested
by a patient's personal representative. The requested information will not include PHI released or
disclosed on or prior to April 13, 2003.
Records of disclosures are retained for a six-year period.
PROCEDURE
1. Upon receiving an inquiry from a resident, the Facility Privacy Official provides the patient or personal
representative with a copy of a Request for an Accounting of Disclosures of PHI (Request) form. (See
sample Request form following this Policy.)
Requests are not evaluated until the Request form is completed and signed by the patient or
personal representative.
2. The Facility Privacy Official reviews and processes the request.
3. The Facility provides a written accounting no later than 60 days after receipt. If the Facility is unable
to meet the 60-day time frame, the Facility may extend the time once by no more than 30 days as
long as the individual is provided with a written statement of the reasons for the delay and the date
by which the Facility will provide the accounting. (See the Notification of Time Extension form in the
Policy "Former Resident's Access to Protected Health Information.")
4. A written accounting is provided to the requestor using an Accounting of Disclosures log. (See sample
log following this Policy.)
a. The accounting will include disclosures during the period specified by the patient or personal
representative in the request. The specified period may be up to six years prior to the date of
the request. Disclosures made on or before April 13, 2003 will not be included in the accounting.
b. The Facility will include known disclosures made by its Business Associates, if aware of any such
disclosures required to be included in an accounting.
c. For each disclosure, the accounting will include:
i. Date the request for disclosure was received;
ii. Name of entity requesting disclosure and, if known, the address of such person or entity;
iii. A brief description of the PHI that was disclosed; and
iv. A brief statement of the purpose of the disclosure that reasonably informs the individual
of the basis for the disclosure.
d. If there are multiple disclosures for health oversight or law enforcement officials for a single
purpose, the Facility may provide:
i. The first disclosure during the accounting period;
ii. The frequency, or number of disclosures made during the accounting period;
iii. The date of the last such disclosure during the accounting period.
5. For disclosures of PHI for research purposes in a project consisting of fifty or more individuals, the
accounting may provide:
a. Name of protocol or other research activity;
b. Description and purpose of research, criteria for selecting particular records;
c. Brief description of the type of PHI disclosed;
d. Date or period of time during which disclosure(s) occurred, including date of last disclosure during
accounting period;
e. Name, address, telephone number of entity that sponsored the research and of the researcher to
whom the information was disclosed;
f. Statement that PHI of the resident may or may not have been disclosed for a particular protocol or
the research activity.
6. The Facility will provide the first accounting to a patient or personal representative within a 12-month
period without charge. However, the Facility may impose a reasonable, cost-based fee for each
subsequent request for an accounting by the same party within the 12-month period, provided the
Facility has informed the requesting party of the charges in advance, giving the party the
opportunity to withdraw or modify the request.
7. The Facility may exclude those disclosures that qualify as an exception.
8. The Facility must document and retain for six years from the date of the accounting:
a. The information required to be included in the accounting, and
b. The written accounting provided to the requesting party.
POTENTIAL AREAS WHERE ACCOUNTING OF DISCLOSURES APPLIES:
1. Disclosures to Public Health Authorities
For the purpose of preventing or controlling disease, injury or disability
To conduct public health surveillance
For public health investigations and interventions
For reporting vital events such as births and deaths
To a foreign government agency at the request of a public health authority
To report child/elder abuse
If necessary, to prevent or lessen a serious and imminent threat to the health or safety of a patient
or the public
2. Disclosures to an Entity Subject to the Food and Drug Administration
To report adverse events, product defects or biological product deviations
To track products
To enable product recalls, repairs or replacements
To conduct post marketing surveillance
3. Disclosures to an Employer
Only PHI specific to a work-related illness or injury, and
Required for the employer to comply with its obligations under federal or state occupational safety
and health laws
4. Disclosures to Health Oversight Agencies
For government benefit program eligibility
To determine compliance with civil rights laws
For civil, administrative or criminal investigations, proceedings or actions
Disclosures in Judicial and Administrative Proceedings
In response to a court order or court ordered warrant
In response to a subpoena, only if approved by Extendicare's Legal Department
6. Disclosures to Law Enforcement Officials
For the purpose of locating a suspect, fugitive, material witness or missing person
About a patient who is or is suspected to be a victim of a crime
Regarding crimes on the Facility premises
Regarding suspicious deaths
In response to an administrative request, civil investigative demand or grand jury subpoena, after
review by Extendicare's Legal Department
For the purpose of averting a serious threat to health or safety
7. Disclosures about victims of abuse, neglect or domestic violence
To a government authority authorized by law to receive reports of abuse, neglect or domestic
violence
8. Disclosure of Deceased Persons PHI
To the Coroner, Medical Examiner or Funeral Directors
To organ procurement organizations
9. Disclosures for research
Only if disclosure was made without an authorization as permitted by the Privacy rule
10. Disclosures for Specialized Government Functions
To Armed Forces personnel for military purposes
To authorized federal officials for the protection of the President and other Federal officials
To other government agencies, if approved by Extendicare's Legal Department
11. Disclosures for Worker's Compensation
As authorized by and to the extent necessary to comply with the law
EXCEPTIONS TO ACCOUNTING OF DISCLOSURES:
Accounting of disclosure does not include disclosures:
. Necessary to carry out treatment, payment, and health care operations
. To the patient for whom the PHI was created or obtained
. Pursuant to a signed authorization by the patient or personal representative
. For the Facility's Directory or to persons involved in the resident's care or other notification
purposes
. For national security or intelligence purposes
. To a correctional institution
. Temporarily suspended by a law enforcement official or health oversight agency (exception applies
only during the period of suspension)
. That are incidental
. As part of a Limited Data Set
. That occurred on or prior to April 13, 2003
Patient or Representative's Signature
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Date: |
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08-Apr-2019 |
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Print Name |
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Lastname, Firstname |
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Representative's Relationship to Patient |
Self |
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