Texas Woman's University University Policy Manual

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1 Texas Wman's University University Plicy Manual Plicy Name: Plicy Number: 6.06 Date Passed: July 2004 Health Insurance Prtability& Accuntability Act (HIPAA) Date Reviewed: September 2008 Next Review: September 2010 Signed By: Chancellr and President PURPOSE T prvide clear standards and prcedures regarding disclsure f prtected health infrmatin. (Applicability: All Texas Wman s University faculty, staff, students, healthcare vlunteers, and business assciates r agents wh are granted access t Prtected Health Infrmatin.) GENERAL POLICY This plicy is the guidance and regulatin cmpnent f Department f Health and Human Services requirements that the Texas Wman s University (TWU) cmmunicate clear and specific cmpliance standards and prcedures t applicable parties regarding the prhibited and required uses and disclsure f Prtected Health Infrmatin (PHI). The plicy and the accmpanying TWU HIPAA OPERATING GUIDLELINES prvides standards and regulatins fr: Ntice f privacy practices Permitted uses and disclsures f PHI Cnsent, and what makes a cnsent valid r defective Verificatin requirements When the minimum necessary standard applies t uses and disclsures Patient rights Access t their wn PHI Use and disclsure f Psychtherapy ntes Authrizatins Uses and disclsures f PHI cnsistent with ntice Reslving cnflicting cnsents and authrizatins T restrict the use and disclsure f their wn PHI T amend their wn PHI T receive an accunting f disclsures f their PHI T receive treatment withut waiving their rights t cmplain Treating a persnal representative as the individual whse health infrmatin is prtected, in the cases f Adults and emancipated minrs Un-emancipated minrs 1

2 Deceased individuals, and Individuals subjected t abuse, neglect, r endangerment Creating de-identified infrmatin frm PHI and regulatins fr use and disclsure f de-identified PHI fr research r ther legitimate purpses Cnfidential cmmunicatins Fax cmmunicatin cmmunicatin Cnfidentiality f substance abuse recrds Strage f PHI Printing and Cpying PHI Dispsal f PHI Disclsures t business assciates and standards fr business assciate cntracts Use and disclsure f PHI that d nt require cnsent Fr marketing Fr underwriting Fr invlvement in an individual s care and fr ntificatin purpses Required by law Fr public health activities Fr health versight activities Fr judicial and administrative prceedings Fr law enfrcement purpses Fr research purpses T avid a serius threat t health and safety Fr specialized gvernment functins Fr wrkers cmpensatin Of deceased individuals Disclsures by whistleblwers and wrkfrce member crime victims Designatin f Privacy Officer and Cntact Persn Training f wrkfrce members Safeguards Cmplaint prcess Sanctins fr imprper use r disclsure Mitigatin f effects f imprper use r disclsure Prhibitin f intimidating and retaliatry acts Changing plicies whenever required Retaining dcumentatin This plicy is ne cmpnent f the requirements f 45 CFR that TWU have a plicy that is cnsistent in scpe with its cvered healthcare activities. Each healthcare cmpnent f TWU must als elabrate n any sectins f this plicy that its missin and scpe requires. Plicy additins made by healthcare cmpnents may be mre restrictive than the requirements f this plicy, but they cannt be less restrictive. Each healthcare cmpnent must als create prcedures and frms that cmply with this plicy, federal, and Texas laws and regulatins, and that are cnsistent with its missin and its peratins. It must als train its wrkfrce in the use f its prcedures and frms. 2

3 Definitins Thrugh ut this plicy: The term individual refers t a patient r a client f the healthcare prvider The term wrkfrce member refers t a member f the faculty, staff, r student bdy wh is an emplyee f the Texas Wman s University r wh is a vlunteer r intern perfrming duties in a healthcare cmpnent f TWU, and wh is supervised by a member f the healthcare cmpnent s administrative structure. Patient Ntice f Health Infrmatin Practices An individual has a right t adequate ntice f the uses and disclsures f PHI that may be made by healthcare cmpnents f TWU, and f the individual s rights and TWU s respnsibilities with respect t PHI. TWU healthcare cmpnents are required t prvide a Ntice f Privacy Practices (NPP) t all individuals, as well as t ther individuals requesting a cpy. Thse persns wh register individuals will be respnsible fr distributing a cpy f the NPP t all individuals. General Requirements TWU healthcare cmpnents must: Develp the required NPP, frms, prcedures, and wrkfrce training related t this sectin; Prvide the ntice n later than the date f the first service delivery, including service delivered electrnically t an individual and, if pssible, determine if a language barrier exists; Make a gd faith effrt t btain an initial written acknwledgement f the receipt f NPP frm the individual and dcument the receipt f the NPP, using an apprpriate acknwledgement frm and filing system; Have the NPP available at the service delivery site fr individuals t take with them; Pst the NPP in a clear and prminent lcatin where it is reasnable t expect individuals seeking service frm the TWU healthcare cmpnent t be able t read the NPP; and Whenever the NPP is revised, prvide the new NPP t all patients r clients n their next visit n r after the effective date f the revisin. If an individual is treated n an emergency basis, the TWU healthcare cmpnent may delay prviding the NPP and receiving an acknwledgement until a practical time. Ntice The NPP must be written in plain language and must cntain the fllwing elements: Header. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET 3

4 ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. This header must be at the tp f the ntice, in capital letters, r therwise in a prminent lcatin n the ntice. Cnsent. Texas law requires that individuals prvide their cnsent t receive treatment frm a healthcare rganizatin. The NPP shall prvide the individual the pprtunity t acknwledge this cnsent in writing, Uses and disclsures. The NPP must cntain: A descriptin f the types f uses and disclsures that the TWU healthcare cmpnent is permitted t make, including at least ne example fr each f the fllwing purpses: Treatment, Payment, and health care Operatins (TPO); A descriptin f each f the purpses fr which the TWU is permitted r required t use r disclse PHI withut the individual s written authrizatin; A statement that ther uses and disclsures will be made nly with the individual s written authrizatin, and that the individual may revke such authrizatin, using the apprpriate frms; A statement that the TWU cmpnent may cntact the individual t prvide appintment reminders r infrmatin abut treatment alternatives r ther health-related benefits and services that may be f interest t the individual; and Individual rights. The NPP must cntain a statement f the individual s rights with respect t PHI and a brief descriptin f the prcedures that the individual wuld use t exercise these rights: The right t request restrictins n certain uses and disclsures f PHI; The right t receive cnfidential cmmunicatins f PHI; The right f the individual t inspect and btain a cpy f the individual s wn PHI; The right t request an amendment t PHI; The right t receive an accunting f disclsures f PHI; and The right f an individual, including an individual wh has agreed t receive the NPP electrnically, t btain a paper cpy f the NPP n request. Healthcare cmpnent s duties. The NPP must cntain a statement that the TWU healthcare cmpnent: Is required by law t maintain the privacy f PHI and t prvide individuals with ntice f its legal duties and privacy practices with respect t PHI; Is required t abide by the terms f the NPP currently in effect; and Reserves the right t change the terms f its NPP and t make the new prvisins effective fr all PHI that it maintains. The 4

5 statement must als describe hw it will prvide individuals with a revised NPP. Cannt delete anything frm the recrd althugh amendments can be cnsidered. Cmplaints. The NPP must cntain a statement that individuals may cmplain t the TWU healthcare cmpnent, and t the Department f Health and Human Services, if they believe that their privacy rights have been vilated, a brief descriptin f hw the individual may file a cmplaint with the TWU healthcare cmpnent, and a statement that the individual will nt be retaliated against fr filing a cmplaint. Cntact. The NPP must cntain the name, r title, and telephne number f a persn r ffice t cntact fr further infrmatin. Effective date. The NPP must cntain the date n which the NPP is first in effect, which may nt be earlier than the date n which the NPP is printed r therwise The Vice President fr Finance and Administratin will review this Operating Plicy with recmmendatins frwarded thrugh nrmal administrative channels t the Chancellr and President. 5

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