Patient Authorization and Disclosure Policy

(INSERT YOUR FACILITY NAME/AND OR LOGO)

Use and Disclosure for Legal Purposes

Effective Date: (Insert Date)

Approved By: (Insert Name Board of Directors) (Insert Name Administrative Team)

PURPOSE: To define accurate uses and requirements for release of protected health information allowed under legal requirement without patient/resident authorization, per State and Federal Regulations.

POLICY: (Your Facility) is committed to protecting the privacy and confidentiality of an individual’s protected health information. This information may be released when required by State and/or Federal law without the authorization of the patient/resident as defined below.

PROCEDURE:

Limited information for identification and location purposes: Protected health information may be disclosed in response to a law enforcement official’s request for such information for the purpose of identifying or locating a suspect, fugitive, material witness, or missing person. The law is intended to include requests by a person acting on behalf of law enforcement such as a media organization making a television or radio announcement seeking the public’s assistance with identifying a suspect. A law enforcement official’s request may be made orally or in writing. The facility is permitted to disclose only:

(a) Name and address (b) Date and place of birth (c) Social Security number (d) ABO blood type and rh factor (e) Type of injury (f) Date and time of treatment (g) Date and time of death, if applicable (h) A description of distinguishing physical characteristics including height, weight, gender, race, hair and eye color, presence or absence of facial hair, scars, and tattoos.

Pursuant to process and as otherwise required by law: Protected health information may be released without patient/resident authorization pursuant to:

(a) Court order (b) Court ordered warrant (c) Subpoena (d) Summons issued by a judicial officer (e) Grand jury subpoena (f) Administrative subpoena or summons (g) Civil or an authorized investigative demand (h) Similar process authorized under the law

The administrative request must meet a three-part test:

1. The information sought is relevant and material to a legitimate law enforcement inquiry 2. The request is specific and limited in scope to the extent reasonably practicable in light of the purpose for which the information is sought 3. De-identified information could not reasonably be used.

Victims of a crime: Protected health information may be disclosed in response to a law enforcement official’s request for such information about an individual who is or is suspected to be a victim of a crime if an individual agrees to the disclosure or the facility is unable to obtain the individual’s agreement because of incapacity or other emergency circumstance provided that:

(a) The law enforcement official represents that such information is needed to determine whether a violation of law by a person other than the victim has occurred, and such information is not intended to be used against the victim; (b) The law enforcement official represents that immediate law enforcement activity that depends upon the disclosure would be materially and adversely affected by waiting until the individual is able to agree to the disclosure; and (c) The disclosure is in the best interests of the individual as determined by the covered entity, in the exercise of professional judgment.

Decedents: The facility may disclose protected health information about an individual who has died to a law enforcement official for the purpose of alerting law enforcement of the death of the individual if the facility has a suspicion that such death may have resulted from criminal conduct.

Crime on premises: The facility may disclose to a law enforcement official protected health information that the facility believes in good faith constitutes evidence of criminal conduct that occurred on the premises of the facility.

Reporting crimes in emergencies. A facility providing emergency healthcare in response to a medical emergency, other than such emergency on the premises of the facility, may disclose protected health information to a law enforcement official if such disclosure appears necessary to alert law enforcement to: (A) the commission and nature of a crime; (B) the location of such crime or of the victim(s) of such crime, and (C) the identity, description, and location of the perpetrator of such crime. Any medical emergencies that the provider believes are the result of abuse, neglect, of domestic violence, the disclosures are regulated to a different standard that exists at (164.510(c).

Other Mandatory Reporting. (Your Facility) will continue to provide reporting to Federal and State Agencies as per licensing requirements. (Option – provide references to those policies and procedures in this section)

Reviewed: (Insert date) Revised: (Insert date) Departments Affected: (all) or (HIM, Business Office, Admitting)

NOTE: This document was developed by Eide Bailly LLP relating to the obligations imposed by the Health Insurance Portability and Accountability Act (HIPAA). Eide Bailly LLP provides no guarantee or warranty of any kind. This document should be modified depending on the particular health care setting.

Addendum to policy regarding North Dakota health care facilities

Reportable diseases

The North Dakota Department of Health is authorized by North Dakota Century Code 23-07-01 to collect and process mandatory reports of communicable diseases by physicians, hospitals, laboratories, and institutions.

33.6.1.1. Reportable Conditions. All reports and information concerning reportable conditions are confidential and not open to inspection. The following designated reportable conditions must be reported to the state department of health by the persons designated in chapter 36-06-02. If any reportable condition is designated by an asterisk, an appropriate sample of isolate must be submitted to the division of microbiology (public health laboratory) in addition to the required report.

1. Anthrax*

2. Botulism*

3. Brucellosis*

4. Campylobacter enteritis*

5. Cancer, all invasive and in situ carcinomas (except basal and squamous cell skin carcinomas or carcinoma in situ of the cervix uteri)

6. Chickenpox (varicella)

7. Chlamydial infections

8. Cholera*

9. Cryptosporidiois

10. Diptheria*

11. Encephalitis (abroviral encephalitides only)

12. Enteric E. coli (includes E.coli 0157:H7 and infections caused by other enterohemorrhagic, enteropathogenic or enteroinvasive E. coli)*

13. Enterococcus, vancomycin resistant (VRE)*

14. Foodborne or waterborne outbreaks

15. Giardiasis

16. Gonorrhea

17. Hantavirus*

18. Haemophilus influenzae infection (invasive infection with haemophilus influenzae isolated from blood, cerebral spinal fluid, or other normal sterile site)*

19. Hemolytic uremic syndrome

20. Hepatitis (specify type)

21. Human immunodeficiency virus (HIV) infection, including acquired immunodeficiency syndrome (AIDS)* (any positive HIV test result)

22. Human immunodeficiency virus (HIV) nucleic acid test result (detectable or nondetectable)

23. Influenza

24. Lead blood level greater than or equal to 10 ug/dl

25. Legionellosis

26. Listeriosis*

27. Lyme disease

28. Malaria*

29. Measles (rubeola)*

30. Meningitis, bacterial (all bacterial species isolated from cerebrospinal fluid)*

31. Meningococcal disease (invasive infection with neisseria meningitides isolated from blood, cerebrospinal fluid or other normal sterile site)*

32. Mumps

33. Nosocomial outbreaks in institutions

34. Pertussis*

35. Plague*

36. Poliomyelitis*

37. Q fever*

38. Rabies (animal or human*)

39. Rocky Mountain Spotted Fever

40. Rubella*

41. Salmonellosis*

42. Scabies outbreaks in institutions

43. Shigellosis*

44. Staphylococcus aureus, methicillin resistant (MRSA) (invasive infection with staphylococcus aureus isolated from blood, cerebral spinal fluid, or other normal sterile site must be forwarded to the North Dakota public health laboratory.

45. Staphylococcus aureus, vancomycin resistant (VRSA) (any staphylococcus aureus isolate demonstrating intermediate or greater resistance to vancomycin of MIC greater than or equal to 8 ug/ml)*

46. Streptococcal infections (invasive infection of streptococcus group A or B or streptococcus pneumoniae isolated from blood, cerebral spinal fluid or other normal sterile site)*

47. Syphillis

48. Tetanus

49. Toxic shock syndrome*

50. Trichinosis

51. Tuberculosis (tuberculosis disease caused by mycobacterium tuberculosis or mycobacterium bovis)*

52. Tularemia*

53. Tumors of the central nervous system

54. Typhoid fever*

55. Unexplained critical illness or death in an otherwise healthy person

56. Unusual cluster of severe or unexplained illnesses or deaths.

57. Weapons of mass destruction suspected event

Trauma Registry

North Dakota Century Code 23-01.2-01. Trauma system established.

23-01.2-01 Trauma registry. Data in the trauma registry is not subject to subpoena or discovery or introduction into evidence in any civil action. Designated trauma centers must participate in the trauma registry. A hospital not designated as a trauma center must provide to the registry a minimum set of data elements for all trauma patients as determined by the health council.

Child Abuse and Neglect

North Dakota Century Code 50-25.1-03 Persons required and permitted to report – To whom reported

50.25.1.3.1 Any physician nurse, dentist, optometrist, medical examiner or coroner, or any other medical or mental health profession, religious practitioner of the healing arts, schoolteacher or administrator, school counselor, addiction counselor, social worker, day care center or any other child care worker, police or law enforcement officer, or member of the clergy having knowledge of or reasonable cause to suspect that a child is abused or neglected, or has died as a result of abuse or neglect, shall report the circumstances to the department if the knowledge or suspicion is derived from information received by that person in that person’s official or professional capacity. A member of the clergy, how, is not required to report such circumstances if the knowledge or suspicion is derived from information received in the capacity of spiritual advisor.

North Dakota Century Code 50-25.1-03.1 Photography and x-rays

50-25.1-03.1 Any person or official required to report under this chapter may cause to be taken color photographs of the areas of trauma visible on a child who is subject of a report and, if indicated by medical consultation, cause to be performed a radiological examination of the child without the consent of the child’s parents or guardian. All photographs taken pursuant to this section must be taken by law enforcement officials, physicians, or medical facility professionals upon the request of any person or official required to report under this chapter.

Photographs and x-rays taken, or copies of them, must be sent to the department or department’s designee at the time of the initial report of child abuse or neglect is made or as soon thereafter as possible.

North Dakota Century Code 50-25-.1-04. Method of Reporting

50-25.1-04. All persons mandated or permitted to report cases of suspected child abuse or neglect shall immediately cause oral or written reports to be made to the department or the department’s designee. Oral reports must b followed by written reports within forty-eight hours if so requested by the department or the department’s designee. A requested written report must include information specifically sought by the department if the reporter possesses or has reasonable access to that information. Reports involving know or suspected institutional child abuse or neglect must be made and received in the same manner as all other reports made under this chapter.

North Dakota Century Code 50-25.1-10. Abrogation of privileged communications

50-25.1-10. Any privilege of communication between husband and wife or between any professional person and person’s patient or client, except between attorney and client, is abrogated and does not constitute grounds for preventing a report to be made or for excluding evidence if any proceeding regarding child abuse, neglect, or death resulting from abuse or neglect resulting from a report made under this chapter.

North Dakota Century Code 50-25.1-11. Confidentiality of records – Authorized disclosures.

50.25.1.11. All reports made under this chapter, as well as any other information obtained, are confidential and must be made available to:

1. A physician who has before the physician a child whom the physician reasonably suspects may have been abused or neglected. 2. A person who is authorized to place a child in protective custody and has before the person a child whom the person reasonably suspects may been abused or neglected and the person requires the information in order to determined whether to place the child in protective custody. 3. Authorized staff of the department, appropriate county social service boards, and appropriate state and local child protection teams. 4. Any person who is the subject of a report; provide, however, that the identity of persons reporting under this chapter is protected. 5. Public officials and their authorized agents who require the information in connection with the discharge of their official duties.

6. A court whenever the court determines that the information is necessary for the determination of an issue before the court. 7. A person engaged in a bona fide research purpose; provided, however, that no information identifying the subjects of a report is made available to the researcher unless the information is absolutely essential to the research purposed and the department gives prior approval. 8. A person who is identified in subsection 1 of section 50-25.1-03, and who has made a report of suspected child abuse or neglect, if the child is likely to or continues to come before the reporter in the reporter’s official or professional capacity. 9. Parents or a legally appointed guardian of a child who is suspected of being, or having been, abused or neglected, provided the identity of persons making reports or supplying information under this chapter is protected. Unless the information is confidential under section 44-04-18.7, when a decision is made under section 50-25.1-05.1 that services are required to provide for protection and treatment of an abused or neglected child, the department shall make a good faith effort to provide written notice of the decision to persons identified in this subsection. The department shall consider any known domestic violence when providing notification under this section.

North Dakota Century Code 50-25.1-14. Unauthorized disclosure of reports-Penalty.

50-25.1-14. Any person who permits or encourages the unauthorized disclosure of reports made of confidential information obtained under the provisions of this chapter is guilty of a class B misdemeanor

North Dakota Century Code 50-25.1-15 - Abandoned infant – Hospital procedure-Reporting immunity.

50.25.1.15. 1. As used in this section: a.“Abandoned infant” mean an abandoned infant as defined in section 27-20-02 and which has been left at a hospital in an unharmed condition. b.“Hospital means a facility licensed under Chapter 23-16. 2. Within 24 hours of receiving an abandoned infant under this section, the hospital shall report to the department, as required by section 50-25.1-03, that an abandoned infant has been left at the hospital. The report may not be made before the parent or the agent leaves the hospital. 3. The hospital and its employees and agents are immune from any criminal or civil liability for accepting an abandoned infant under this section.

Adults with Developmental Disabilities

North Dakota Century Code 25-01.3-04 – Reporting of abuse, neglect, or exploitation – Immunity for good faith reports.

25.1.3.4 Every medical, mental health, or developmental disabilities professional, educational professional, police, or law enforcement officer, or caretaker having knowledge of or reasonable cause to suspect that an adult with developmental disabilities or mental illness coming before the individual providing services in that individual’s official or professional capacity is abused, neglected, or exploited shall report the circumstances of that abuse, neglect, or exploitation to the project.

Refer to North Dakota Century Code 25-01.3 for the entire law regarding adults with developmental disabilities.

25-01.3 Vulnerable Adults – According to North Dakota Century Code 50-25.2 reporting of abuse or neglect of vulnerable adults is considered voluntary.

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