TITLE:

RELEASING PROTECTED HEALTH INFORMATION TO PREVENT A SERIOUS THREAT TO HEALTH OR SAFETY

POLICY:
Columbia University Medical Center will release Protected Health Information (PHI) without the patient's authorization in order to prevent a serious threat to health or safety.

PURPOSE
The purpose of the Policy is to describe a set of specific circumstances under which Columbia University Medical Center will release a patient's PHI without the patient's authorization to prevent a serious threat to health or safety.

PROCEDURES:

1. Reasonable and good faith belief required. Columbia University Medical Center will disclose a patient's PHI without the patient's authorization if there exists a reasonable and good faith belief that:
1. Disclosure is necessary to prevent or reduce a serious and imminent threat to the health or safety of the public.
1. The disclosure will be made only to a person or persons reasonably able to prevent or reduce the threat, and



2. The disclosure may be made to the target of the threat.


2. Disclosure is necessary for law enforcement authorities to identify or apprehend an individual.
1. The disclosure will be made if the patient admits participation in a violent crime that caused or may have caused serious physical harm to the victim; or



2. The disclosure will be made if it appears from all the circumstances that the patient escaped from a correctional institution or from lawful custody.


2. When a disclosure will not be made to prevent a serious threat to health or safety. Columbia University Medical Center will not disclose the patient's PHI to prevent a serious threat to health or safety if the patient's admission that he/she participated in a violent crime was made:
1. during the course of treating the patient for his/her propensity to commit the criminal conduct that is the basis for the disclosure; or



2. during the course of counseling or therapy; or



3. when the patient is requesting treatment, counseling, therapy, or a referral for treatment for the criminal conduct that is the basis for the disclosure.


3. Only limited PHI will be disclosed to prevent a serious threat to health or safety.
1. If a disclosure of the patient's PHI is made to prevent a serious threat to health or safety, the PHI disclosed will be limited to:
1. the patient's statement in which he/she admitted participating in a crime;
2. the patient's name and address;
3. the patient's date and place of birth;
4. the patient's social security number;
5. the patient's ABO blood type and rh factor, if known;
6. the date and time of the patient's treatment;
7. the date and time of death, if applicable; and
8. a description of any distinguishing physical characteristics including height, weight, sex, race, hair and eye color, presence or absence of facial hair (i.e., beard or moustache), scars, and tattoos.


2. Specially protected PHI, such as genetic or HIV/AIDS information will not be disclosed. (Refer to the Genetic and HIV/AIDS Information Policies.)


4. Documentation of disclosures required. Documentation of any disclosures made pursuant to this Policy will be made and included in the patient's medical record. (Refer to the Accounting of Disclosures Policy for a description of the required documentation.)



5. Questions. Questions about whether a disclosure is required to prevent a serious threat to health or safety, or what information may be disclosed should be directed to the employee's supervisor or the HIPAA Privacy Officer.



6. 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:         HIPAA Privacy Officer, Departments, Administrators