HIPAA Quick Reference
Guide For Employees
My job requires me to
notify various agencies, like the Department of Public Health, of
information about our patients. Is there anything special that I
need to do with respect to HIPAA?Yes, you may be required to notify these agencies in accordance with Medical Center policies. While a patient authorization form is not needed, we are required to account for these in order to produce a list (called an accounting of disclosures) for the patient upon request. Patients are informed of this right to an 'accounting of disclosures' in our Notice of Privacy Practices.
The following types of disclosures must be tracked:
- Reports of child abuse, neglect, or domestic violence
- Any disclosure required by law (state encounter data, infectious disease reporting, etc.)
- Disclosures to funeral directors, coroners, and medical examiners
- Disclosures in accordance with a judicial subpoena
- Public health activities (births, deaths, public health investigations, adverse events, work related injuries, FDA required reporting, etc.)
- Health oversight activities (audits and investigations by Government benefit or regulatory programs)
- Specialized government functions (law enforcement custodial
situations)
- Disclosure of certain law enforcement purposes (identification of a suspect or missing person, identification of a crime victim, suspected crime, etc.)
- Disclosures to organ procurement and banking organizations
- Disclosures to a third party when the safety of an individual is at risk (threat of violence)
- Disclosure for research with a waiver of informed consent from the IRB
- Workers' compensation disclosures
- Disclosures made in error (e.g. faxed to a wrong number or
message left on the wrong answering machine)
How do I keep track of
these disclosures?To facilitate the accounting of disclosures, we have a centralized electronic system to log the disclosures. Any disclosure meeting the criteria outlined in the Purpose of Disclosure Definition Table should be entered into the system. The information captured in the system is linked to the patient's medical record number (MRN), and will allow us to respond completely and accurately to patient requests for an accounting of disclosures.
How do I get access to
the disclosure tracking system?For access to the Disclosure tracking system, complete and submit a system access request form (SARF). This form can be found here. For training, log-in ID and password assistance, contact medical records 4-0444.
The University of Chicago Medical Center | 5841 South Maryland Avenue | Chicago, IL 60637
HPOwebmaster@bsd.uchicago.edu