PURPOSE

To encourage awareness of patient privacy rights and U.P. Home Health & Hospice legal duties with respect to these rights and the use and disclosure of protected health information (PHI).

POLICY

U.P. Home Health & Hospice will respect and safeguard all protected health information of the patients it serves.

Patients will be provided with information about their privacy rights at the time of admission to U.P. Home Health & Hospice.

To assist with fully understanding patient privacy rights and responsibilities, all policies will be available to the organization personnel, patients, and their representatives as well as other organizations and the interested public.

DEFINITION

Protected health information (PHI) is any information about health status, provision of health care, or payment for health care that can be linked to a specific individual in ANY form (verbal, written, electronic). This is interpreted rather broadly and includes any part of a patient’s medical record or payment history. Examples of identifiers are: names, all geographical identifiers smaller than a state (except for the initial three digits of a zip code), dates (other than year) directly related to an individual, phone numbers, fax numbers, email addresses, Social Security numbers, medical record numbers, Health insurance beneficiary numbers, account numbers, certificate/license numbers, vehicle identifiers and serial numbers including license plate numbers, device identifiers and serial numbers, web Uniform Resource Locators (URLs), Internet Protocol (IP) address numbers, biometric identifiers, including finger, retinal and voice prints, full face photographic images and any comparable images, and any other unique identifying number, characteristic, or code except the unique code assigned by the investigator to code the data.

PROCEDURE

1. Patients will be provided with information about their privacy rights in the organization’s Statement of Patient Privacy Rights, which will be given to the patient during the admission visit. The patient’s privacy rights include:

1. A right to adequate notice of the uses and disclosures of protected health information that may be made by U.P. Home Health & Hospice.(See “Notice of Privacy Practices” Addendum 2-012.A.)
2. A right to request privacy protection for protected health information. (See “Patient Requests for Privacy Restrictions” Policy No. 2-019 and “Patient Requests for Confidential Communication” Policy No. 2-020.)
3. A right of access to inspect and retain a copy of their protected health information. (See “Patient Requests for Access to PHI” Policy No. 2-021.)
4. A right to request that the organization amend protected health information or a record about the individual in a designated record set for as long as the protected health information is maintained in the designated record set. (See “Patient Requests to Amend PHI” Policy No. 2-022.)
5. A right to receive an accounting of disclosures of protected health information made by U.P. Home Health & Hospice in the six (6) years prior to the date on which the accounting is requested. (See “Patient Requests for Accounting of PHI Disclosures” Policy No. 2-023.)

2. U.P. Home Health & Hospice will make a good faith effort to obtain the patient’s written acknowledgement of receipt of this notice. A signature/initials line for this acknowledgement is located on the consent form. If an acknowledgement cannot be obtained, the admitting clinician will document his/her efforts to obtain the acknowledgement and the reason why it was not obtained in the clinical note.

3. The notice will be promptly revised and distributed whenever there is a material change to the uses or disclosures, the individual’s rights, organization’s legal duties, or other privacy practices stated in the notice. A material change to any term of the notice will not be implemented prior to the effective date of the revised notice, unless required by law.

4. U.P. Home Health & Hospice will prominently post the notice and make the notice available through its website.

5. The patient’s legal representative may exercise the patient’s rights when a patient is incompetent or a minor.

6. When a patient has questions about their privacy rights, requests additional information, or would like to exercise one (1) of these rights, they will be referred to the Privacy Officer.