TITLE:

DISCLOSURES OF A PATIENT'S PROTECTED HEALTH INFORMATION TO INDIVIDUALS INVOLVED IN THE PATIENT'S CARE OR FOR PURPOSES OF NOTIFICATION

POLICY:
Columbia University Medical Center may disclose a patient's Protected Health Information (PHI) to a member of the patient's family, a friend of the patient, or to another individual if the family member, friend, or other individual is directly involved in the patient's care and the disclosure is necessary for the patient's welfare.

Columbia University Medical Center will limit the PHI disclosed to the family member, friend, or other individual to health-related signs and symptoms and to information designed to help the patient deal with his/her illness or treatment, including setting and changing appointments, receiving instructions for post-visit care, or picking up treatment-related items.

Columbia University Medical Center may also disclose a limited amount of the patient's PHI in order to locate the patient or to locate or notify a patient's family member or friend.

PURPOSE :
Columbia University Medical Center is committed to protecting patient privacy and to disclosing patient PHI in accordance with the patient's desires. However, when the patient's desires are not known or have not been expressed, it may be necessary to disclose a patient's PHI to a member of the patient's family, a friend of the patient, or someone else who is directly involved in the patient's care. It may also be necessary to disclose a limited amount of the patient's PHI in order to locate the patient (for example, in case the patient elopes) or to locate or notify a member of the patient's family or a friend of the patient. This Policy describes the procedures for releasing and limitations surrounding the release of a patient's PHI to someone directly involved in the patient's care or for location or notification purposes.

PROCEDURES:

1. When the patient is physically present or otherwise available..



1. An individual who is physically present with the patient will be assumed to be an individual who is directly involved in the patient's care unless the patient specifically states otherwise.



2. Generally, before disclosing a patient's PHI to an individual who is physically present with the patient, the patient will be asked whether he/she agrees to the disclosure and will be given an opportunity to object.
1. If the patient does not object to the disclosure, disclosures can be made to the individual at that time or any time in the future until such time as the patient revokes his/her consent.



2. If the patient fails to respond, a healthcare professional treating the patient may use his/her professional judgment and experience to decide whether disclosing the PHI to the person physically present with the patient is in the patient's best interest.



3. If the patient objects to the disclosure, the Department will provide the patient with a copy of the Request for Restrictions on Uses and Disclosures of Health Information and ask the patient to complete it and forward it to the HIPAA Privacy Officer.


3. The healthcare professional may disclose a patient's PHI to an individual physically present with the patient without first asking for the patient's agreement when, based on the healthcare professional's judgment, the healthcare professional is reasonably sure under the circumstances that the patient does not and would not object.



4. Documentation of a general nature, such as pre-printed discharge instructions, patient education forms, and other materials, may be provided to the patient's family member or friend or other person directly involved in the patient's care without first obtaining a written authorization from the patient.



5. Copies of a patient's PHI may only be released to a patient's family member, friend of the patient, or someone directly involved in the patient's care if the individual requesting the PHI presents a valid authorization (signed by the patient) that has not been revoked.


2. When the patient is unable to communicate.
1. An individual who is physically present with the patient will be assumed to be an individual who is directly involved in the patient's care unless the patient specifically states otherwise.



2. The healthcare professional may disclose a patient's PHI to an individual physically present with a patient who is unable to communicate when, based on the healthcare professional's judgment, the healthcare professional is reasonably sure under the circumstances that the patient would not object.



3. Documentation of a general nature, such as pre-printed discharge instructions, patient education forms, and other materials, may be provided to the patient's family member or friend or other person directly involved in the patient's care without first obtaining a written authorization from the patient.



4. Copies of a patient's PHI may only be released to a patient's family member, friend of the patient, or someone directly involved in the patient's care if the individual requesting the PHI presents a valid authorization (signed by the patient) that has not been revoked.


3. When the patient is not present.
1. If the individual requesting the PHI is physically present, the PHI may be released only if the individual:
1. is known to be a family member or personal friend of the patient; or



2. is someone who the patient has previously identified as someone involved in the patient's care; or



3. is someone whose direct involvement in the patient's care is obvious.


2. The PHI that is released must be:
1. Disclosed orally (not provided in writing);



2. Limited to the minimum amount of information necessary to allow the individual to help the patient;



3. Directly relevant to the individual's involvement in the patient's care; and



4. Necessary to help the patient with health care or with payment for health care.


3. Documentation of a general nature, such as pre-printed discharge instructions, patient education forms, and other materials, may be provided to the patient's family member or friend or other person directly involved in the patient's care without first obtaining a written authorization from the patient.



4. Copies of a patient's PHI may only be released to a patient's family member, friend of the patient, or someone directly involved in the patient's care if the individual requesting the PHI presents a valid authorization (signed by the patient) that has not been revoked.



5. Questions regarding whether an authorization is valid or whether release of a patient's PHI to a particular individual is appropriate should be directed to the HIPAA Privacy Officer.


4. Releasing a patient's PHI for purposes of locating the patient or locating or notifying a patient's family member or friend of the patient.
1. Columbia University Medical Center may disclose a patient's PHI, as necessary, to the patient's family members, the patient's friends, or other individuals for purposes of locating the patient (if the patient has eloped).



2. Columbia University Medical Center may disclose a patient's PHI, as necessary, to the patient's family members, the patient's friends, or other individuals to notify them of the patient's location, general condition, or death.



3. Columbia University Medical Center may disclose a patient's PHI, as necessary, to locate or identify a member of the patient's family, a friend of the patient, or someone responsible for the patient's care in order to notify the individual of the patient's location, general condition, or death.


5. Definitions

Protected Health Information is information about a patient, including demographic information that may identify a patient, that relates to the patient's past, present or future physical or mental health or condition, related health care services or payment for health care services.

RESPONSIBILITY:         Departments, HIPAA Privacy Officer