Policies
Accounting of Disclosures Standard
Accounting of Disclosures
Accountable disclosures of a patient’s PHI are available to a patient or to their representative upon their request. The period of accounting can go back up to six years prior to the request date and any patient may make this request. All requests are referred to the Medical Records Department or Health Information Management Office. While a Request for Accounting Form is preferred for submission to process the request, Tenet may accept alternative form for the request such as a written letter from the patient. The NPP provides some details on the patients’ right to accounting of disclosures.
Compensation modifiers do not impact discretionary compensation awards, and are separate from other disciplinary action that might be applied for a quality, compliance or ethics issue.
- Accountable Disclosure Contains
- Date of the disclosure
- Name of entity or person who received the PHI
- Address of entity or person who received the PHI if known
- Brief description of the PHI disclosed
- One of the following:
- Brief statement of the purpose of disclosure
- Copy of request from Secretary of Health and Human Services to investigate or determine Tenet’s compliance with the Privacy Rule
- Copy of request obtained (related to disclosure for an accounting period)
- Scope of Request
- Six-year period prior to the date of the request
- Period of less than six years if the requestor specifies a shorter period
- Costs for Accounting Disclosures
- No charge for the first accounting to a patient in any twelve-month period
- Reasonable cost-based fee for each subsequent request during twelve-month period
- Patient has to be informed about the estimated costs for the request
- Accounting Request Form outlines policy on charging fees for accounting
- Verifying Identification of Requestor
- Positive identification of the requestor includes driver’s license or other picture identification or copy of identification for requests by mail
- Timelines
- Request must be completed within sixty days of receipt for the accounting
- Requestor must be notified in writing with the reasons for the delay and the date when the request can be completed by
- Request must be completed within ninety days of receipt of request
- Tracking Process
- Tracking accountable disclosure requests must be done for functional areas such as
- Radiology
- Quality
- Emergency Room
- Health Information Management
- Clinics
- Documentation
- Accountable disclosure information
- Written accounting and responses created under this policy are retained per record management and record retention schedule
- Written requests for accounting received and related documentation
- Maintained by Medical Records Department or Health Information Management Office
- Tenet Facility Leadership
- Ensures procedures are operationalized to comply with this standard
- Ways to monitor compliance to this policy and its procedures
- Monitoring activity is reported to the Privacy and Security Compliance Officer
- Date of the disclosure
- Name of entity or person who received the PHI
- Address of entity or person who received the PHI if known
- Brief description of the PHI disclosed
- One of the following:
- Brief statement of the purpose of disclosure
- Copy of request from Secretary of Health and Human Services to investigate or determine Tenet’s compliance with the Privacy Rule
- Copy of request obtained (related to disclosure for an accounting period)
- Scope of Request
- Six-year period prior to the date of the request
- Period of less than six years if the requestor specifies a shorter period
- Costs for Accounting Disclosures
- No charge for the first accounting to a patient in any twelve-month period
- Reasonable cost-based fee for each subsequent request during twelve-month period
- Patient has to be informed about the estimated costs for the request
- Accounting Request Form outlines policy on charging fees for accounting
- Verifying Identification of Requestor
- Positive identification of the requestor includes driver’s license or other picture identification or copy of identification for requests by mail
- Timelines
- Request must be completed within sixty days of receipt for the accounting
- Requestor must be notified in writing with the reasons for the delay and the date when the request can be completed by
- Request must be completed within ninety days of receipt of request
- Tracking Process
- Tracking accountable disclosure requests must be done for functional areas such as
- Radiology
- Quality
- Emergency Room
- Health Information Management
- Clinics
- Documentation
- Accountable disclosure information
- Written accounting and responses created under this policy are retained per record management and record retention schedule
- Written requests for accounting received and related documentation
- Maintained by Medical Records Department or Health Information Management Office
- Tenet Facility Leadership
- Ensures procedures are operationalized to comply with this standard
- Ways to monitor compliance to this policy and its procedures
- Monitoring activity is reported to the Privacy and Security Compliance Officer
- Medical Records Department or Health Information Management Director or designee shall perform and process Accounting of Disclosure requests
- Reasons Why Request May Be Denied
- Information used to carry out Treatment, Payment and health care Operations (TPO)
- Information to the patient
- Incident to a use or disclosure otherwise permitted
- Pursuant to an Authorization
- Information for Tenet’s patient registry, to persons involved in the patient’s care or for certain other notification purposes (e.g., disclosures in certain emergencies)
- Information for national security or intelligence purposes
- To correctional institutions or law enforcement officials
- As part of a limited data set
- Any disclosure that occurred prior to April 14, 2003
- Suspension of Accounting
- Accounting of disclosures made to a health oversight agency or law enforcement official
- Tenet is informed the disclosure to the patient may be impeding an agency’s or official’s activities
- Terms and length of suspension
- Length of time is provided in a written request by agency or enforcement official
- Thirty days from date of agency or law enforcement agency’s oral request
- Subsequent length of time provided in written request by agency during the thirty-day period
- Oral requests must be documented with identity of agency or official making the request
- Multiple Disclosures
- Disclosures of PHI to the same person or entity for a single purpose pursuant to EC.PS.02.01 Uses, Disclosure and Minimum Necessary Standard
- Secretary of Health and Human Services Request for
- Information on the first disclosure during the accounting period
- Frequency, periods or number of disclosures made during accounting period
- Date of the last disclosure during the accounting period
- Disclosures for Research Purposes
- Research Involving Fifty of More Individuals may be included in accounting of disclosures and include
- Name of the protocol or activity
- Description of research protocol or activity
- Purpose of research and criteria for selecting records
- Brief description of the type of PHI that was disclosed
- Date or period of time when disclosures happened or may happened
- Date of the last disclosure during the accounting period
- Name, address, and telephone number of sponsoring entities for research
- Name of researcher to whom the information was disclosed
- Statement that PHI of the individual may or may not have been disclosed
- Tenet assists the patient with contacting sponsoring research entity if it is reasonably likely that patient’s PHI was disclosed for the research protocol or activity
- Reasons Why Request May Be Denied
- Information used to carry out Treatment, Payment and health care Operations (TPO)
- Information to the patient
- Incident to a use or disclosure otherwise permitted
- Pursuant to an Authorization
- Information for Tenet’s patient registry, to persons involved in the patient’s care or for certain other notification purposes (e.g., disclosures in certain emergencies)
- Information for national security or intelligence purposes
- To correctional institutions or law enforcement officials
- As part of a limited data set
- Any disclosure that occurred prior to April 14, 2003
- Suspension of Accounting
- Accounting of disclosures made to a health oversight agency or law enforcement official
- Tenet is informed the disclosure to the patient may be impeding an agency’s or official’s activities
- Terms and length of suspension
- Length of time is provided in a written request by agency or enforcement official
- Thirty days from date of agency or law enforcement agency’s oral request
- Subsequent length of time provided in written request by agency during the thirty-day period
- Oral requests must be documented with identity of agency or official making the request
- Multiple Disclosures
- Disclosures of PHI to the same person or entity for a single purpose pursuant to EC.PS.02.01 Uses, Disclosure and Minimum Necessary Standard
- Secretary of Health and Human Services Request for
- Information on the first disclosure during the accounting period
- Frequency, periods or number of disclosures made during accounting period
- Date of the last disclosure during the accounting period
- Disclosures for Research Purposes
- Research Involving Fifty of More Individuals may be included in accounting of disclosures and include
- Name of the protocol or activity
- Description of research protocol or activity
- Purpose of research and criteria for selecting records
- Brief description of the type of PHI that was disclosed
- Date or period of time when disclosures happened or may happened
- Date of the last disclosure during the accounting period
- Name, address, and telephone number of sponsoring entities for research
- Name of researcher to whom the information was disclosed
- Statement that PHI of the individual may or may not have been disclosed
- Tenet assists the patient with contacting sponsoring research entity if it is reasonably likely that patient’s PHI was disclosed for the research protocol or activity
- As required by law (e.g., mandated disease reporting)
- Public health authority authorized by law that collects information to prevent or control disease, injury or disability
- Public health authority or other government authority authorized by law that receives reports of child abuse or neglect
- Governmental authority authorized by law that receives reports of abuse, neglect or domestic violence under certain circumstances
- Person subject to jurisdiction of the Food and Drug Administration
- Covered Entity or Public health authority authorized by law to receive information about person potentially exposed to communicable disease or a t risk of contracting or spreading a disease or condition necessary to facilitate a public health intervention or investigation
- Employer(where patient is in their workforce) associated with medical surveillance of the workplace or to evaluate a work-related illness or injury
- Health oversight agency with activities that use health information to determine compliance
- Health care system
- Government benefit programs
- Entities subject to government regulatory programs
- Entities subject to civil rights laws
- In the course of any judicial or administrative proceeding
- As required by law, including certain types of wounds and physical injuries
- Pursuant to a court order or court-ordered warrant, subpoena or summons or administrative request
- Law enforcement official based on the request for PHI on covered entity’s own initiative
- Coroner or medical examiner to assist in authorized duties
- Funeral director to carry out its duties with respect to a decedent
- Organ procurement organization for organ, eye or tissue donation purposes
- Pursuant to waiver of authorization requirement for the use and disclosure of PHI for research purposes, research related to deceased persons, or development of a research protocol or for other similar purposes preparatory to research
- Third party to prevent serious threat to health or safety
- U.S. or foreign military command authorities about a member of U.S. or foreign armed forces
- Federal government officials for protective services to the President of the United States, foreign heads of state and government officials and conducting related investigations
- As authorized by and to comply with workers’ compensations laws
- Any other circumstance where PHI is disclosed to a third party and an exception is not available (impermissible disclosure)
Sample Request for an Accounting Attachment A
Information Privacy and Security Glossary of Definitions
Sample Accounting of PHI Disclosures Tracking Attachment B
EC.PS.03.00 Patient Rights Policy
EC.PS.02.03 Public Interest and Benefit Activities
EC.PS.02.01 Uses Disclosure and Minimum Necessary Standard
EC.PS.02.00 Patient Information Privacy Policy
EC.PS.01.03 Business Associate and Data Use Agreement Standard