TITLE:

DISTRIBUTION OF THE NOTICE OF PRIVACY PRACTICES

POLICY:
Columbia University Medical Center will develop and distribute to its patients a Notice of Privacy Practices that describes how a patient's Protected Health Information (PHI) may be used and disclosed, the rights and responsibilities of patients with respect to their PHI, and the responsibilities of Columbia University Medical Center with respect to PHI it creates, collects, and maintains.

PURPOSE :
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandates development and distribution of a formal document, a Notice of Privacy Practices (NOPP), to the health care organization's patients. The primary goals of the NOPP are to describe:

1. how the health care organization will use and disclosure a patient's PHI;



2. the patient's rights and responsibilities with respect to his/her PHI; and



3. the covered entity's duties with respect to a patient's PHI.

This Policy describes how the Columbia University Medical Center NOPP will be distributed and acknowledged, and who to contact in case of questions about the NOPP or its contents.

PROCEDURES:

1. Each patient that visits Columbia University Medical Center will receive and be asked to acknowledge receipt of the NOPP.



1. When a patient comes to Columbia University Medical Center for services, the health care provider's office will determine whether the patient has received the most recent version of the NOPP by:



1. Checking the patient's file. If the patient received the NOPP on a previous visit, the patient's file will contain a Patient Acknowledgment signed by the patient, or



2. Checking the IDX system. If the patient received the NOPP on a previous visit, the patient's file in the IDX system should contain documentation of receipt and acknowledgment.


2. If there is no documentation of a previous receipt and acknowledgment of the NOPP, the health care provider's office will:



1. Provide the patient with the most current version of the NOPP;



2. Ask the patient to acknowledge receipt of the NOPP by signing the Patient Acknowledgment form;



3. Make a copy of the signed Patient Acknowledgment form and give the copy to the patient;



4. If the patient refuses to acknowledge receipt of the NOPP, document the patient's refusal on the Patient Acknowledgment form along with any efforts that were made to obtain the patient's acknowledgment;



5. File the Patient Acknowledgement form in the patient's file; and



6. Record the receipt and acknowledgment in the IDX system.


3. If the patient's file contains a signed Patient Acknowledgment form, or the IDX screen indicates the patient has already received and acknowledged receipt of the NOPP, another NOPP may, but is not required to be provided to the patient.



2. Requests for a NOPP. . If any individual requests a copy of the Columbia University Medical Center NOPP, the person receiving the request should provide him/her with one.



3. Documentation. All documentation related to the receipt and acknowledgment of the NOPP will be maintained for a minimum of six (6) years. Signed Patient Acknowledgment forms in the patient's file will not be included as part of a Designated Record Set.



4. Questions. Questions from patients about the NOPP or its contents should be directed to the HIPAA Privacy Officer. Questions about the distribution and acknowledgment process should be directed to the employee's supervisor or the HIPAA Privacy Officer.



5. Definitions

Designated Record Set (DRS) means the set of clinical and/or financial information, records, and documents the healthcare provider would provide to the patient upon a request from the patient to access his/her PHI at that healthcare provider's office.

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