EVMS Medical Group | Use and Disclosure of PHI - Without Authorization or Notification

Category: Privacy

Date: March 2003

Reviewed/Revised: April 2013

Policy

It is the policy of EVMS Medical Group to provide patient healthcare information without an authorization or opportunity for the patient to agree or object under these strict circumstances as outlined in § 164.512:

Uses and disclosures required by law. EVMS Medical Group may use or disclose protected health information to the extent that such use or disclosure is required by law and is limited to the relevant requirements of such law.
Uses and disclosure for public health activities. EVMS Medical Group may use or disclose protected health information for the public health activities and purposes described as such to:
- prevent or control a disease, injury or disability; report a communicable disease, birth, death, child abuse or neglect, adverse effects of food or dietary supplements; report defects or problems with a biologic product; report defective products to enable product recalls, repairs or replacements; follow up with the use of products to comply with the requirements of the Food and Drug Administration, Investigate a work-related illness or injury
Disclosures about victims or abuse, neglect or domestic violence.

In the event that an EVMS Medical Group provider or health professional believes a patient is a victim of abuse, neglect or domestic violence, protected healthcare information will be provided to a government authority, social service, protective services agency or other agency authorized by law to receive report of such abuse, neglect or domestic violence.
1. The provider or health professional will inform the patient if/when this information will be provided to report the abuse, neglect or domestic violence to an authorized agency.
2. The patient can refuse to have the abuse, neglect or domestic violence reported.
3. The provider or health professional can overrule the patient’s request to not report the abuse, neglect or domestic violence if it is determined that the reporting is necessary to prevent serious harm to the individual or other potential victims.
4. If the patient is unable to agree to have the information reported about abuse, neglect or domestic violence, a law enforcement or public health official will act upon the information only if it is determined that waiting until the patient agrees to report the information could adversely affect the outcome.
5. The provider or health professional will not inform a personal representative of the report of abuse, neglect or domestic violence if s/he believes the personal representative is responsible for the abuse, neglect or other injury.
Use and disclosure for health oversight activities.
1. EVMS Medical Group may provide protected health information to a health oversight agency for the purpose of conducting audits, civil, administrative or criminal investigations, inspections, licensure, disciplinary actions or other activities necessary for operations.
2. EVMS Medical Group may not provide confidential information if the patient is under investigation or to investigate if the patient qualifies to receive public benefits when the patient’s health status is needed to make the decision about receiving the public benefit.
Disclosures for judicial and administrative proceedings.

EVMS Medical Group may disclose protected health information in the course of any judicial or administrative proceeding as follows:
1. EVMS Medical Group may provide protected health information in response to a court order. Only the information requested may be provided.
2. EVMS Medical Group may provide information to a law enforcement agency seeking protected health information if the agency has attempted to reach the patient using the patient’s last known address, if the notice for the information explains the need for the protected health information, and the time for the patient to raise objections to the law enforcement agency has elapsed.
Disclosures for law enforcement purposes:
1. EVMS Medical Group may provide protected health information to a law enforcement official for the purpose of identifying and/or locating a suspect, fugitive, material witness or missing person. This information is limited to:
  - Name and address
  - Date and place of birth
  - Social security number
  - Blood type and rh factor
  - Type of injury
  - Date and time of treatment
  - Date and time of death, if applicable, and
  - A description of distinguishing physical characteristics, including height, weight, gender, race, hair and eye color, presence or absence of facial hair (beard or moustache), scars and tattoos.
2. EVMS Medical Group may provide information to a law enforcement agency seeking protected health information after first attempting to reach the patient.
3. EVMS Medical Group may provide information about certain types of wounds or other physical injuries upon court order, court-ordered warrant, subpoena, summons, grand jury subpoena, civil investigative demand or other similar process when it is determined that the information is relevant and material to the investigation and that de-identified information could not be used.
4. EVMS Medical Group is not permitted to release information about the patient’s DNA, DNA analysis, dental records or samples, typing or analysis of body tissues or fluids.
5. EVMS Medical Group prohibits the law enforcement agency from using the healthcare information for purposes other than the reason it was requested and requires the agency to return the information to the hospital or destroy the information at the end of the litigation.
6. EVMS Medical Group may release protected health information about a patient in response to a law enforcement official’s request if the patient is suspected of being a victim of a crime and agrees that the protected health information may be provided. If the patient is incapacitated and cannot agree to the release of the information, the information may be provided if it will not be used against the patient; the investigation would be adversely affected by waiting for the patient to agree to the release of the information; or providing the information is in the best interest of the patient.
7. EVMS Medical Group may release protected health information about a patient who has died to a law enforcement official if the department suspects that the death may have resulted from criminal activity.
8. EVMS Medical Group may release protected health information to a law enforcement official if there is evidence of criminal conduct on EVMS Medical Group premises.
Uses and disclosures for decedents.
1. EVMS Medical Group may disclose protected health information to a coroner or medical examiner for the purpose of identifying a deceased person, determining the cause of death, or other duties authorized by law.
2. EVMS Medical Group may release protected health information to funeral directors to carry out their duties with respect to the deceased. This disclosure may be made prior to, and in reasonable anticipation of, the individual's death.
Uses and disclosures for cadaveric organ, eye, or tissue donation purposes. EVMS Medical Group may release protected health information to organ procurement organizations or other entities for the purpose of facilitating organ, eye or tissue donation or transplantation.
Uses and disclosures for research in specific circumstances. EVMS Medical Group may use or disclose protected health information for research, regardless of the source of funding of the research. (See Research Policy for a list of requirements)
Uses and disclosures to avert a serious threat to health or safety. EVMS Medical Group may release protected health information if it believes the information will prevent or lessen a serious/imminent threat to the health or safety of a person or the public. This information may be provided to the person(s) who are the target of the threat or for the identification or apprehension of an individual making the threat.
Uses and disclosures for specialized government functions
1. EVMS Medical Group may release protected health information to law enforcement officials when it appears that an individual has escaped from a correctional institution or from lawful custody.
2. EVMS Medical Group may release protected health information of Armed Forces personnel to assure the proper execution of the military mission if a notice has appeared in the Federal Register stating the military command authorities and the purposes for the protected healthcare information.
3. EVMS Medical Group may release protected health information to the Department of Veterans Affairs (DVA) of a patient who is a member of the Armed Forces upon separation or discharge from the military service for the purpose of determining eligibility of benefits administered by the Secretary of Veterans Affairs.
4. EVMS Medical Group may release protected health information of foreign Armed Forces personnel to assure the proper execution of the military mission if a notice has appeared in the Federal Register stating the military command authorities and the purposes for the protected healthcare information.
5. EVMS Medical Group may release protected health information to authorized federal officials to conduct intelligence, counter-intelligence or other national security activities authorized by the National Security Act.
6. EVMS Medical Group may release protected health information to authorized federal officials to provide protective services to the President, to foreign heads of state or for the conduct of investigations.
7. EVMS Medical Group may release protected health information to the Department of State to make medical suitability determinations for security clearance or for mandatory service abroad.
8. EVMS Medical Group may release protected health information to a correctional institution or law enforcement official having custody of an inmate to provide healthcare to the person, to ensure the health and safety of the patient or other inmates, to ensure the health and safety of the officers, employees or others at the correctional facility, to ensure the health and safety of those responsible for the transportation of the inmates, to ensure the health and safety of law enforcement on the premises of the facility and to maintain the safety and security of the facility.
Disclosures for worker's compensation. EVMS Medical Group may release protected health information to comply with laws relating to workers’ compensation or other similar programs that provide benefits for work-related injuries or illness.