AccountingofDisclosures-HCAEthicsCompliance.docVIP

SCOPE: All Company-affiliated facilities including, but not limited to, hospitals, ambulatory surgery centers, imaging and oncology centers, physician practices, shared services centers, and each entities’ respective departments. PURPOSE: To ensure that each Company-affiliated facility, and their respective departments, understands the requirement to populate and provide an Accounting of Disclosures of Protected Health Information to all patients as required by the Health Insurance Portability and Accountability Act (HIPAA), Standards for Privacy of Individually Identifiable Health Information (Privacy Standards), 45 CFR Parts 160 and 164, the Health Information Technology for Economic and Clinical Health Act (HITECH) component of the American Recovery and Reinvestment Act of 2009 (ARRA), and any and all other Federal regulations and interpretive guidelines promulgated thereunder. POLICY: Each Company-affiliated facility must provide a written accounting of disclosures (AOD) of protected health information (PHI) to authorized individuals that a facility has made during the six years prior to the date on which the accounting is requested. AODs do not need to be provided for any disclosures on or prior to April 13, 2003. Requests for an AOD must be made in writing or the verbal request must be documented. A system must be in place for all departments (including but not limited to: Radiology, Quality, Emergency Room, and Health Information Management) within the facility to accurately and completely track all disclosures and have such information available for a minimum of six (6) years as required by the HIPAA Privacy Standards and this policy. The right to request an AOD and the process for making a request must be outlined in the Notice of Privacy Practices. PROCEDURE: An individual has a right to receive an accounting of disclosures of PHI made by a facility in the six (6) years prior to the date on which the accounting is requested, except for the fol