Oklahoma State University Center for Health Sciences
OSU-CHS Centernet

Privacy Policies & Procedures

Section 5 - Uses and Disclosures Requiring an Opportunity for the Individual to Agree or Object

 

Title:Use and Disclosure for Facility Directories Policy: PRV-05.01
Category: HIPAA Compliance Authority: 45 CFR §
HIPAA Section:
164.510
Standard:Uses and Disclosures requiring an opportunity for the individual to agree or to object Responsibility: Health Care Components
Effective Date: 04/14/2003
Download a printable PDF of this policy
Approved by: OSU Legal Counsel Revised: 7/1/2013
Purpose

To identify what types of uses and disclosures require the individual to agree or object.

Policy

OSU may use or disclose protected health information, provided that the individual is informed in advance of the use or disclosure and has the opportunity to agree to or prohibit or restrict the use or disclosure, in accordance with the applicable requirements of this policy. OSU may orally inform the individual of and obtain the individual's oral agreement or objection to a use or disclosure permitted by this policy.  §164.510

Use and Disclosure for Facility Directories – Permitted Uses and Disclosure.  Except when an objection is expressed in accordance with the Opportunity to Object and Emergency Circumstances section of this policy, OSU may:  §164.510(a)(1)

  1. Use the following protected health information to maintain a directory of individuals in its facility: §164.510(a)(1)(i)
    1. The individual’s name;  §164.510(a)(1)(i)(A)
    2. The individual’s location in the facility;  §164.510(a)(1)(i)(B)
    3. The individual’s condition described in general terms that does not communicate specific medical information about the individual; and  §164.510(a)(1)(i)(C)
    4. The individual’s religious affiliation; and  §164.510(a)(1)(i)(D)
  2. Use or disclose for directory purposes such information:  §164.510(a)(1)(ii)
    1. To members of the clergy; or  §164.510(a)(1)(ii)(A)
    2. Except for religious affiliation, to other persons who ask for the individual by name.  §164.510(a)(1)(ii)(B)

Opportunity to Object – An OSU provider must inform an individual of the protected health information that it may include in a directory and the persons to whom it may disclose such information (including disclosures to clergy of information regarding religious affiliation) and provide the individual with the opportunity to restrict or prohibit some or all of the uses or disclosures permitted by Use and Disclosure for Facility Directories section of this policy.  §164.510(a)(2)

Emergency Circumstances - If the opportunity to object to uses or disclosures required by the Opportunity to Object section of this policy cannot practicably be provided because of the individual's incapacity or an emergency treatment circumstance, a OSU provider may use or disclose some or all of the protected health information permitted by the Use and disclosure for facility directories section of this policy for the facility's directory, if such disclosure is:  §164.510(a)(3)(i)

  1. Consistent with a prior expressed preference of the individual, if any, that is known to the OSU provider; and  §164.510(a)(3)(i)(A)
  2. In the individual's best interest as determined by the OSU health care provider, in the exercise of professional judgment.  §164.510(a)(3)(i)(B)

The OSU health care provider must inform the individual and provide an opportunity to object to uses or disclosures for directory purposes as required by the Opportunity to Object section of this policy when it becomes practicable to do so.  §164.510(a)(3)(ii)

Procedure

OSU does not actively keep a facility directory of patients that is more of a hospital function.  However, it is OSU’s practice to question any individual when seeking the whereabouts of a patient within the clinic system.  If the individual is not already authorized, OSU will seek authorization from the patient, giving the patient an opportunity to agree or object.


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Title: Use and Disclosures for Involvement in the Individual’s Care and Notification Purposes Policy: PRV-05.02
Category: HIPAA Compliance Authority: 45 CFR §
HIPAA Section:
164.510(b)
Standard: Uses and Disclosures requiring an opportunity for the individual to agree or to object Responsibility: Health Care Components
Effective Date: 04/14/2003
Download a printable PDF of this policy
Approved by: OSU Legal Counsel Revised: 7/1/2013
Purpose

To identify what types of uses and disclosures are needed for the individual’s care.

Policy

OSU may use or disclose protected health information, provided that the individual is informed in advance of the use or disclosure and has the opportunity to agree to or prohibit or restrict the use or disclosure, in accordance with the applicable requirements of this policy. OSU may orally inform the individual of and obtain the individual's oral agreement or objection to a use or disclosure permitted by this policy.  §164.510

Permitted Uses and Disclosures – OSU in accordance with the Uses and Disclosures with the Individual Present, Limited Uses and Disclosures when the Individual in not Present, or Uses and Disclosures when the individual is Deceased sections of this policy may disclose to a family member, other relative, or a close personal friend of the individual, or any other person identified by the individual, the protected health information directly relevant to such person’s involvement with the individual’s health care or payment related to the individual’s health care.  §164.510(b)(1)(i)

OSU may use or disclose protected health information to notify, or assist in the notification of (including identifying or locating), a family member, a personal representative of the individual, or another person responsible for the care of the individual of the individual's location, general condition, or death. Any such use or disclosure of protected health information for such notification purposes must be in accordance with the Uses and Disclosures with the Individual Present, Limited Uses and Disclosures when the Individual in not Present, or Uses and Disclosures when the Individual is Deceased sections of this policy, as applicable.  §164.510(b)(1)(ii)

Uses and Disclosures with the Individual Present - If the individual is present for, or otherwise available prior to, a use or disclosure permitted by the Permitted Uses and Disclosures Section of this Policy and has the capacity to make health care decisions, OSU may use or disclose the protected health information if it:  §164.510(b)(2)

  1. Obtains the individual’s agreement;  §164.510(b)(2)(i)
  2. Provides the individual with the opportunity to object to the disclosure, and the individual does not express an objection; or  §164.510(b)(2)(ii)
  3. Reasonably infers from the circumstances, based on the exercise of professional judgment, that the individual does not object to the disclosure.  §164.510(b)(2)(iii)

Limited Uses and Disclosures When the Individual is not Present - If the individual is not present, or the opportunity to agree or object to the use or disclosure cannot practicably be provided because of the individual's incapacity or an emergency circumstance, OSU may, in the exercise of professional judgment, determine whether the disclosure is in the best interests of the individual and, if so, disclose only the protected health information that is directly relevant to the person's involvement with the individual's care or payment related to the individual's health care or needed for notification purposes. OSU may use professional judgment and its experience with common practice to make reasonable inferences of the individual's best interest in allowing a person to act on behalf of the individual to pick up filled prescriptions, medical supplies, X-rays, or other similar forms of protected health information.  §164.510(b)(3)

Uses and Disclosures for Disaster Relief Purposes -  OSU may use or disclose protected health information to a public or private entity authorized by law or by its charter to assist in disaster relief efforts, for the purpose of coordinating with such entities the uses or disclosures permitted by the Permitted Uses and Disclosures section of this policy. The requirements in paragraphs Uses and Disclosures with the Individual Present, Limited Uses and Disclosure when the Individual is not Present, and Uses and disclosures when the individual is Deceased of this policy apply to such uses and disclosures to the extent that OSU, in the exercise of professional judgment, determines that the requirements do not interfere with the ability to respond to the emergency circumstances.  §164.510(b)(4)

Uses and Disclosures when the Individual is Deceased - If the individual is deceased, OSU may disclose to a family member, or other persons identified in the Permitted Uses and Disclosures section of this policy who were involved in the individual's care or payment for health care prior to the individual's death, protected health information of the individual that is relevant to such person's involvement, unless doing so is inconsistent with any prior expressed preference of the individual that is known to the covered entity.  §164.510(b)(5)

Procedure

OSU will follow the above policy

OSU will seek to obtain patient authorization for any uses and disclosures where one is needed as stated in the policy above.

In instances where the patient is not present or available to make such authorizations, the employee will use their best judgment in determining to use or disclose information.


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