Patient’s Right to Request Privacy Restrictions & Confidential Communications

Purpose: To establish guidelines and facilitate compliance with the rules governing the rights of patients of Welcome Home Health (“WHH”) to request privacy restrictions on the use and disclosure of protected health information (“PHI”) and the right to request confidential communications, in accordance with the Health Insurance Portability and Accountability Act (“HIPAA”), the Health Information Technology for Economic and Clinical Health Act (“HITECH”) component of the American Recovery and Reinvestment Act (“ARRA”), and any and all other Federal regulations and interpretive guidelines promulgated thereunder.

Policy: Patients of the WHH will be provided the right to request restriction of certain uses and disclosures of their PHI that is contained within the designated record set, and the right to request confidential communications by alternative means or alternative locations, as outlined below.

There may be state laws relating to patient privacy that apply to the disclosures set forth in this Policy. In the event that such laws provide more protection to PHI than HIPAA, WHH must follow the more stringent law.

Definitions:

Protected Health Information is defined under 45 CFR 160.103 as “Individually identifiable health information”:

(1) Except as provided in paragraph (2) of this definition, that is:
(i) Transmitted by electronic media;
(ii) Maintained in electronic media; or
(iii) Transmitted or maintained in any other form or medium.

(2) Protected health information excludes individually identifiable health information in: (i) Education records covered by the Family Educational Rights and Privacy Act, as amended, 20 U.S.C. 1232g;
(ii) Records described at 20 U.S.C. 1232g(a)(4)(B)(iv); and

(iii) Employment records held by a covered entity in its role as employer.

Individually identifiable health information is information that is a subset of health information, including demographic information collected from an individual, and:

(1) Is created or received by a health care provider, health plan, employer, or health care clearinghouse; and
(2) Relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual; and

(i) That identifies the individual; or
(ii) With respect to which there is a reasonable basis to believe the information can be used to identify the individual.

Designated record set (“DRS”) is defined under 45 CFR 164.501 as:

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(1) A group of records maintained by or for a covered entity that is:
(i) The medical records and billing records about individuals maintained by or for a covered health care provider;
(ii) The enrollment, payment, claims adjudication, and case or medical management record systems maintained by or for a health plan; or
(iii) Used, in whole or in part, by or for the covered entity to make decisions about individuals.

(2) For purposes of this paragraph, the term record means any item, collection, or grouping of information that includes PHI and is maintained, collected, used, or disseminated by or for a covered entity.

Procedure:
I. Requests for Privacy Restrictions

1. WHH must permit a patient to request restrictions on the use and disclosure of PHI as contained in the designated record set for:
a. Uses or disclosures or PHI about the individual to carry out treatment, payment, or

health care operations; and
b. Disclosures for involvement in the individual ‘s care and notification purposes as

permitted under § 164.510(b).

2. Requests for restrictions must be presented in writing and routed to the Privacy Officer.

3. The Privacy Officer and his/her designee are the only individuals who may agree to any restrictions.

4. The patient’s request and the written communication notifying the patient of the Privacy Officer’s decision must be filed with the designated record set.

5. Unless the request cannot be denied by law, the Privacy Officer must ensure that the request can be met and that the designated record set is flagged accordingly.

6. If WHH agrees to a restriction it may not use or disclose PHI in violation of such restriction, except that, if the individual who requested the restriction is in need of emergency treatment and the restricted PHI is needed to provide the emergency treatment, WHH may use the restricted PHI, or may disclose such information to a health care provider, to provide such treatment to the individual. If restricted PHI is disclosed to a health care provider for such emergency treatment, WHH will request that such health care provider not further use of disclose the information.

7. If WHH agrees to a restriction it will not be effective to prevent disclosures otherwise required by the Secretary of HHS or in which individual authorization is not required.

8. WHH may not deny a patient’s request for restrictions or limitations for disclosures to the patient’s health plan for payment or health care operations purposes if the patient has paid

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out of pocket in full for the health care item or service and the PHI pertains solely to that

item or service.

9. WHH may deny any other request that is not a required restriction.

10. The Privacy Officer or designee must notify the patient in writing if the request for a privacy restriction is denied.

11. WHH must document the following:
a. The designated record sets that are subject to restriction; and
b. The titles of the persons or offices responsible for receiving and processing requests

for restrictions by individuals.

12. All correspondence and associated documentation related to patient requests for restrictions, including denials, must be maintained and retained for a minimum of six (6) years.

13. WHH may terminate its agreement to a restriction, if:
a. The individual agrees to or requests the termination in writing;
b. The individual orally agrees to the termination and the oral agreement is documented;

or
c. WHH informs the individual that it is terminating its agreement to a restriction, except

that such termination is only effective with respect to PHI created or received after it has so informed the individual. Note: restrictions may not be terminated without the patient’s permission for disclosures to the patient’s health plan for payment or health care operations purposes if the patient has paid out of pocket in full for the health care item or service and the PHI pertains solely to that item or service.

14. Image and Media data collection: Your media that are collected through our application is used only for the personalisation of your profile and for your diagnosis, and is not shared to any third party vendors. You have full control of your data and can be removed by you at any point of time and no copies of your data will be retained in our servers.

II. Confidential Communications

1. WHH will permit individuals to request to receive communication of PHI from WHH by alternative means or at alternative locations. WHH will accommodate all reasonable requests.

2. The patient, or patient’s legal representative, must complete and sign a written request for confidential communications. This request may be submitted to WHH at any time.

3. The workforce member receiving the request from the patient will review it to verify that it contains all of the applicable information in order for WHH to implement the request. WHH will not require an explanation from the patient as to the basis for the request as a condition of providing communications on a confidential basis.

4. The written request will be routed to the Privacy Officer or designee, who will be responsible for notifying any additional parties that may need to take appropriate action.

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5. WHH shall develop a process to ensure that the appropriate patient address/phone as

reflected in the system/record is used when communicating with the patient.

6. If the alternate phone number is not in service, or the correspondence sent to the alternate address is returned undeliverable, the situation will be promptly reported to the Privacy Officer. The Privacy Officer or designee will notify the patient that they must respond within seven (7) days or WHH will begin communicating with them via other means and addresses provided.

7. If a patient wishes to revise the alternate means or alternate address, they must submit another written request for confidential communications to WHH.

8. If a patient wishes to revoke the alternate means or address, they must submit a written request for revocation of the confidential communications.

9. WHH will retain all written communications relative to the request/revocation of confidential communication for a minimum of six (6) years.

References:

45 CFR 164.522

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SAMPLE Request for Privacy Restrictions Form

Please complete the following information:

1. Today’s date: __________________________________________ 2. Patient Full Legal Name __________________________________________ 3. Patient Street Address __________________________________________ __________________________________________

4. City, State and Zip __________________________________________ 5. Patient Birth Date __________________________________________

6. Date(s) associated with information to be restricted (e.g., date of office visit, treatment, or other health care services). ____________________________________________

7. Describe the information to be restricted (e.g., lab test results, physician notes) ________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

8. What is your reason for making this request? (Optional) ________________________________________________________________________

________________________________________________________________________ 9. Signature of patient/legal representative

________________________________________________________________________ Forward to:

WHH Privacy Officer Welcome Home Health, Inc. 5113 NW 143rd St. Suite 227 Vancouver, WA 98685 Phone: 360-993-8872

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SAMPLE Denial of Request for Privacy Restriction Letter

Patient Name:
Date of Birth:
Patient Medical Record Number:

Dear (patient):

At Welcome Home Health (“WHH”) each patient is provided the right to request restrictions on uses and/or disclosures of his or her protected health information (“PHI”). Each request is reviewed subject to the limitations outlined in HIPAA Federal Standards for Privacy of Individually Identifiable Health Information (45 CFR Parts 160 and 164) and applicable state laws.

Reason for denial of request (check those that apply):

❑ Based on our system and process requirements we are unable to make the restriction you requested.

❑ The request was not made in writing.
❑ The request was not made to WHH’s Privacy Officer or designee per the Notice of

Privacy Practices and WHH Policy.

You may request a review of this denial by contacting WHH’s Privacy Officer. The request must be made in writing.

Please contact me with any questions or concerns you might have. <Signature of Privacy Officer>

WHH Privacy Officer Welcome Home Health, Inc. 5113 NW 143rd St. Suite 227 Vancouver, WA 98685 Phone: 360-993-8872

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SAMPLE Request for Confidential Communications Form

I hereby request that my protected healthcare information including clinical information (e.g., test results, patient instructions), billing information, and other communications (e.g., patient surveys) be communicated to me via the alternate address/phone listed below.

I understand that this request for Confidential Communications will apply to all future communications related to the date of service listed below unless I request a change in writing.

NOTE: This request only applies to communications from Welcome Home Health (“WHH”). If you wish to request Confidential Communications from your insurance company or other health care providers, you must contact them directly.

I understand that if correspondence sent to an alternate address is returned undeliverable, if the alternate phone is disconnected/out of service, or if I fail to respond in a timely manner to communications via an alternate address/phone that I have provided, WHH will communicate with me via other means and/or at other locations.

This request is for the date of service/treatment of ___________________________________________.

ALTERNATE ADDRESS/PHONE:

NOTE: Only U.S. addresses and phone numbers will be accepted. All information requested below must be completed in order for this request to be processed by WHH.

Patient Name: __________________________________________________ Street Address: __________ _______________________________________ Suite/Apt. Number (if applicable): _____________________
City: _______________________________________________

State: ______________________ Zip Code: __________________ Phone Number: ________________________________

Patient/Patient Representative Signature: _________________________________________________ Date: _________________________ Time: ____________________

OTHER REQUESTS (e.g., alternate means): All other requests must be referred to WHH’s Privacy Officer. (insert phone number and/or office location).

WHH USE ONLY: Patient Med Record Number: ____________ Patient Acct Number: _____________ _

Initials Date

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SAMPLE Revocation of Confidential Communications Request Form I hereby revoke my request for confidential communications for the date of service/treatment of ________________________________________________.

NOTE: This revocation only applies to communications from Welcome Home Health. If you wish to revoke a request for Confidential Communications submitted to your insurance company or other health care providers, you must contact them directly.

System updated to reflect alternate information by:

_________________________________________________

Patient Name: ________________________________________________________

Patient/Patient Representative Signature: ________________________________________________ Date: _____________________________ Time: ____________________

WHH USE ONLY: Patient Med Record Number: ____________ Patient Acct Number: ____________ _

System updated to reflect permanent information by:

_________________________________________________

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Initials Date