Subject: HIPAA Privacy Notice Availability Policy Number: PSEC_007
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SACRED HEART HEALTHCARE SYSTEM
SACRED HEART HOSPITAL
421 CHEW STREET
ALLENTOWN, PA 18102-3490
HEALTH INFORMATION MANAGEMENT POLICY AND PROCEDURE MANUAL
Subject: HIPAA Privacy Notice Availability - SHH Policy Number: PSEC_007
Approval: ______Initial Effective Date: 4/2003
General Counsel and CCO Most Recent Revision: 6/2014
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I. PURPOSE:
The purpose of this policy is to ensure that Sacred Heart Hospital employees understand the Health Insurance Portability and Accountability Act of 1996 (HIPAA) requirement to provide a HIPAA Privacy Notice to all patients prior to their first treatment or services after April 14, 2003. Each department must inform their patients of their rights with respect to protected health information (PHI) and electronic Protected Health Information (ePHI) as well as our legal duties. The patient must acknowledge receipt of the HIPAA Privacy Notice.
II. SCOPE:
Sacred Heart Hospital and Healthcare System their departments, including, but not limited to, Sacred Heart Hospital, Transitional Care Facility, Older Adult Behavioral Medicine Center, Family Practice Centers, Sacred Heart Pharmacy and any employees of a partnership that is under the corporation.
III. RESPONSIBILITY:
It is the responsibility of all employees, Medical Staff, volunteers, students to understand HIPAA as it relates to PHI and ePHI and to comply with Sacred Heart Hospital policies and procedures. This understanding is acknowledged annually during our personnel review process in our Corporate Compliance agreement. The departmental managers are responsible for the enforcement of this policy.
IV. REFERENCES
Health Insurance Portability and Accountability Act (HIPAA), Standards for Privacy of Individually Identifiable Health Information, 45 CFR Parts 160 and 164.
V. PROCEDURE/METHODS
There will be two (2) different versions of the HIPAA Privacy Notice available to all patients. They are English 12pt and Spanish 12pt. See Appendix A – HIPAA Privacy Notice Available Forms for specifics.
There will be multiple methods of acquiring acknowledgement of receipt for the HIPAA Privacy Notice. These methods correspond to where the patient receives their first service or treatment after April 14, 2003. See Appendix B – HIPAA Privacy Notice Distribution. It is our policy to assure that the patient has received our HIPAA Privacy Notice prior to treatment or provision of service at Sacred Heart Hospital or any Sacred Heart Health System entity.
VI. EXCEPTIONS
There are no exceptions to this policy.
Disclaimer Statement
This policy and the implementing procedures are intended to provide a description of recommended courses of action to comply with statutory or regulatory requirements and/ or operational standards. It is recognized that there may be specific circumstances not contemplated by laws or regulatory requirements that make compliance inappropriate. For advice in these circumstances, please consult with Risk Management/Patient Safety and/or Legal Services.
Policy Reviewed Dates: 7/2010; 2/2013; 3/2014
Privacy Notice Reviewed Dates: 7/2010; 11/2013
Revised Dates: 6/2014
Typist Name: DMajka
APPENDIX A – HIPAA PRIVACY NOTICE AVAILABLE FORMS
1. English 12pt font, Form # 17137 Revised 3/01/2014,
2. Spanish 12pt font, Form # 17251 Revised 3/01/2014,
3. English with Signature Line 12pt font, Form # 17137sig Revised 3/01/2014
4. Spanish with Signature Line 12pt font, Form # 17251sig Revised 3/01/2014
5. Forms will be ordered through Purchasing by using a Purchase Requisition as needed by the individual departmental registration area(s).
PRIVACY NOTICES:
Sacred Heart Hospital or Health System 17137
Sacred Heart Hospital or Health System Spanish 17251
PRIVAACY NOTICES WITH SIGNATURE LINE:
Sacred Heart Hospital or Health System 17137sig
Sacred Heart Hospital or Health System Spanish 17251sig
APPENDIX B – HIPAA PRIVACY NOTICE DISTRIBUTION
Patients at Sacred Heart Hospital:
- Any patient being admitted to Sacred Heart Hospital for Inpatient Services, Short Procedures or Outpatient Surgery will receive an appropriate version of our HIPAA Privacy Notice at the time of Admission. Patients will acknowledge receipt of the HIPAA Privacy Notice through their signature on our Conditions of Admissions Form # 00441.
- Our Privacy Notice will be distributed to patients each time they sign our Conditions of Admission. This fulfills HIPAA’s concern that patients have the opportunity to exercise their full rights under HIPAA including but not limited to their inclusion in our facility’s directory and their ability to object to certain uses and disclosures that we may make.
- Admissions will update the patient’s demographic record with the current version of our HIPAA Privacy Notice if it is noted on the Online Patient Registration Screen (Exhibit A) that the patient has not received or does not have a current version (YYV, YY=Year and V=Current Version). This will be accomplished by updating the patient’s demographic record and adding the appropriate code into the Privacy Notice field.
- I understand I have the right to receive and review the Sacred Heart Hospital’s Notice of Privacy Practices prior to signing this consent as per the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand I have the right to restrict how my medical information is used or disclosed to carry out treatment, payment, or health operations. I understand that Sacred Heart Hospital is not required to honor my requested restrictions. However, if they agree, the restrictions will be binding. I understand that I have the right to revoke this consent for treatment, at any time, except to the extent that healthcare provider’s at Sacred Heart Hospital have taken action relying on my consent. I understand that I can only revoke this consent in writing, and the revocation must include my name, address, telephone number and the date of this consent.
- All outpatients will receive our Privacy Notice during the Registration Process. If it is noted on the Online Patient Registration Screen (Exhibit A) that the patient has not received or does not have a current version (YYV, YY=Year and V=Current Version) of the Privacy Notice, the patient will be given an appropriate copy of the Privacy Notice.
- Registration will update the patient’s demographic record with the current version of our Privacy Notice if it is noted on the Online Patient Registration Screen (Exhibit A) that the patient has not received or does not have a current version (YYV, YY=Year and V=Current Version). This will be accomplished by updating the patient’s demographic record and adding the appropriate code into the Privacy Notice field.
- Registration will have the patient SIGN our Privacy Notice Acknowledgement Log Sheet that states they have received a copy of our Privacy Notice. This log sheet is printed double-sided. The Registrar will date the sheet and indicate a date change by skipping a line and entering the new date on the next line.
- All other patients at Sacred Heart Hospital departments will sign the appropriate HIPAA Privacy Notice and receive a copy of the same notice. The signed HIPAA Privacy Notice will become part of the patient’s Medical Record maintained in that department. If the current version of the HIPAA Privacy Notice is not on the patient’s Medical Record, they will be given the appropriate version to sign and their own copy of the same HIPAA Privacy Notice.
PHDE010B ONLINE PATIENT REGISTRATION 3/19/03
17:14:36
REGISTRANT CHARMING, CINDERELLA Age 078Y Rce W MSts M MR# 80-47-15
Address...... 127 CASTLE ROAD Notes.. N
City/State... NORTHAMPTON PA 18015 Home Phone... 610 437-1234
Birth Date... 9/21/1924 Sex F VIP SSN# 679-02-3568
Employer..... DORNEY PARK Family Phys.. GARCIA, JOSE R
Privacy Notice: 141
GUARANTOR CHARMING, PRINCE HUSBAND
Address...... 123 CASTLE DRIVE Notes.. N
City/State... FAIRYVILLE PA 12345 Home Phone...
Birth Date... 5/17/1961 Sex M VIP SSN# 123-56-5578
Employer..... *NONE Work Phone...
SPOUSE/PARENT CHARMING, PRINCE HUSBAND
Address...... 123 CASTLE DRIVE
City/State... FAIRYVILLE PA 12345 Home Phone...
Birth Date... 5/17/1961 Sex M VIP SSN# 123-56-5578
RELATIVE DEVILLE, LUELLA DAUGHTER
Address...... 127 CASTLE ROAD
City/State... BETHLEHEM PA 18015 Home Phone... 610 437-1234
Birth Date... 5/14/1956 Sex F VIP SSN# 567-82-5648
Exhibit A
Patients at All Sacred Heart Health System Entities:
- All patients at Sacred Heart Healthcare System entities will sign the appropriate HIPAA Privacy Notice and receive a copy of the same notice. The signed HIPAA Privacy Notice will become part of the patient’s Medical Record at that entity’s facility. If the current version of the HIPAA Privacy Notice is not on the patient’s Medical Record, they will be given the appropriate version to sign and their own copy of the same HIPAA Privacy Notice.