1

Insert Agency Name and Address

______

XYZ Agency includes XYZ Children's Center, XYZ Work Scholarship Connection, XYZ Children’s Foundation & Corporation, & XYZ Therapeutic Foster Care Program.

Photography, Audio-Visual Taping, & Use of Client Protected Heath Information Policy and Procedure

  1. Regulatory References:

45 CFR Parts 160-164

JCAHO

U.S.C. Section 1732

  1. XYZ Agency ’ Purpose Statement and Definitions:
  1. This policy and procedure is provided for the clarification of permitted disclosures and uses of client and staff protected health information (PHI), photographs, audio-visual taping, and “stories” for reproduction, publication, transmission, broadcast. As well as exhibited by or through XYZ in connection with programs or activities related to publicity or fundraising and staff development outside the agency.
  1. For the definitions to the policy and procedure, please refer to the XYZ HIPAA Glossary.
  1. XYZ Agency ’ Policy:
  1. Applicability: This policy and procedure applies to XYZ Agency inclusive of the affiliates identified above.
  1. Notifications & Special Considerations: Special Notifications & Considerations apply to the use, disclosure and access to PHI, photographs and audio-visual taping. Please refer to the XYZ Regulatory Policy and Procedure Cover Sheet for a list. If there are any questions, please call the Privacy Officer and/or a Clinical Information Specialist (CIS) for clarification.
  1. Verification: Please refer to the XYZ Regulatory Policy and Procedure Cover Sheet for methods of verification.
  1. XYZ adheres to all federal, state, and local requirements for confidentiality of its clients and families.
  1. When using PHI, photographs, audio-visual tapes of clients, families and XYZ staff, XYZ shall always respect the rights of children, their parents or guardians and agency staff.
  1. Uses of client photographs, audio-visual tape recordings, and PHI:

a)Authorization Not Required:

  1. Documentation of Injury, Abuse or Neglect: As mandated by law to report cases of actual or suspected abuse or neglect of children, XYZ may photograph injuries as part of the documentation required for actual or suspected abuse or neglect.
  2. Photographs for Identification: It is XYZ policy to take photographs of clients currently in care for identification purposes. These photographs are kept in the clinical record (photos may be kept in other significant locations e.g., medical records, on-call books).

a)It is permitted to share limited information with law enforcement for identification and location purposes (includes missing persons):

b)type of injury

c)date and time of treatment

d)a description of distinguishing physical characteristics, including health, weight, gender, race, hair and eye color, presence or absence of facial hair, scars and tattoos.

  • For a complete list please see the Release of Information Policy and Procedure.

e)There are regulations regarding:

  1. what can be shared for investigations into crime;
  2. reporting crime on premises;
  3. crimes in emergencies (if someone was being treated on an emergency basis due to a crime); and
  4. victims of crime.

f)In situations where we are required to report (e.g., stabbing or shooting) and/or to avert a serious threat to health and safety we can still make proper notifications: "A CE may consistent w/ applicable law and standards of ethical conduct, use/disclose PHI if the CE, in good faith, believes the use/disclosure is necessary to prevent or lessen a serious an imminent threat to the health/safety of a person or the public;"

g)Per federal, state and local law, an authorization is not required for photos or other medium that documents injuries, abuse or neglect. However, photos or audio-visual taped recordings may not be used for any other purpose without prior authorization from the client and/or their parent/legal guardian.

b)Authorization Required:

  1. Marketing and Public Relations:

a)XYZ photographs children and families that have received or are receiving services to help in agency publicity and fundraising efforts. PHI, photographs, audio-video tapings are shared with the community to help raise public awareness and much-needed funds. At times, XYZ staff may also be photographed, audio-video taped and/or their PHI used for stories for publicity and fundraising efforts.

b)Some examples of when PHI, photograph, audio-video tapes may be used are: in annual reports, newsletters, public service announcements, presentations to community groups, in news reports about Hillside or specific programs at XYZ.

  1. Education:

a)As XYZ strives to provide quality care to clients, families and the communities we serve, photographs, audio-visual taping, and/or PHI of clients/families and/or staff may be used for the education of our staff as well as for groups in the community.

  1. Media Release or Law Enforcement:

a)It is possible that injuries may occur when a client is classified as a missing person or as a potential victim of a crime.

b)It is XYZ policy to take photographs of these injuries as part of our report, care and treatment.

c)Best practice is to ask the client if they object to us sharing the photographs with law enforcement.

d) If they object, the staff shall use their professional judgement based on all the facts and information in this policy and procedure whether to share the photo.

e)For purposes that are not covered in the above section- “Authorization not Required” an authorization would be required.

f)At times local media may ask to photograph, audio-visual tape or interview clients/families and/or staff for events.

  1. In recognizing and being sensitive to our clients, in all cases where authorization is required, it is best practice to ask the child for authorization first. If the child does not give authorization, it would be best practice not use their PHI, photograph or audio-visual tape even if their legal guardian authorizes such use and disclosure.
  2. For all the above purposes, the Authorization forTaking and Releasing of Photographs, Audio-Visual Tapes and PHI – Fundraising and Public Relations form #ADM-6 is required. The authorization must be signed and dated by the client (if eligible due to age or law), parent/legal guardian and witnessed.
  3. Authorization for Taking and Releasing of Photographs, Audio-Visual Tapes and Stories – Fundraising and Public Relations form # is required for the use of staff images and information for publicity and fundraising.
  1. School Photographs:

For those clients who attend one of XYZ’s educational centers, photographs may be taken for school projects, yearbook, and/or educational programs. For this purpose, an Authorization for Taking and Displaying of Photographs and Audio-Visual Tapes Within the Residential and Day Treatment Schools must be signed and dated by the client (if eligible due to age or law), a parent/legal guardian and witnessed.

  1. Ownership, Storage, and Retention of photographs, videotapes, & other medium:

a)Ownership: XYZ owns the photographs, audio-visual tapes, and other medium used to record the images of the client and/or their family.

b)Storage/Maintenance:

i.All client and/or family images from any medium shall be kept in a secure manner that ensures timely retrieval when requested.

ii.All client and/or family images from any medium used for care and treatment that is maintained in the clinical record, shall be retained according to the applicable laws for proper record keeping. In most cases, it is 3 years past the age of majority of the client (if a minor). However, a Clinical Information Specialist must be contacted before the destruction of any materials from a clinical record.

iii.All client and/or family images from any medium used by the Marketing Department for marketing purposes will be either destroyed following approved use deadline or permanently retained in the Marketing Department according to federal and state business records retention requirements.

iv.It is recommended that a reference directory inventory be maintained. The directory shall include date and name of event, and a confidential means of referencing the client’s and/or family name (e.g., initials on the medium with full names in a database or master index).

  1. XYZ Agency Procedure:

a)XYZ Marketing and Public Relations staff will obtain a written authorization for those situations identified above from the applicable client/family/staff. Prior to the use of their information, XYZ staff shall review the information to be used in the publicity and/or fundraising event with the client/family/staff. The XYZ staff shall obtain from the client/family/staff a written acknowledgement that the intended document has been reviewed with them prior to its use, they understand how it will be used and agree to its use as written, photographed, and/or audio-visual taped.

b)Authorization: Client and/or Family

  1. Parent/Legal Guardian authorization shall be obtained for each authorization.
  2. In those cases where state law permits the child to authorize the use of their image or information, the child’s authorization will be obtained.
  3. In the case where a child’s parents have had their parental rights terminated,authorization must be sought through the DSS Caseworker who shall obtain written approval from the DSS Commissioner or their Designee.
  4. Authorization to use photographs, audio-videos, or PHI of clients and families does not condition any current or future treatment/services.
  5. Authorizations shall be obtained as the need/event arises by the Marketing and/or Foundation staff.

c)Authorization: Staff

  1. Parent/Legal Guardian authorization shall be obtained for each authorization.
  2. Authorization to use photographs, audio-videos, or PHI of staff shall not engender privileged employment status.
  3. Authorizations shall be obtained as the need/event arises by the Marketing and/or Foundation staff.

d)Restrictions/ “Opt Out”:

  1. At any time, the client, parent/legal guardian, and/or staff may restrict and/or rescind the use of their photographs, audio-video images, or other PHI from any current or future uses.
  2. If they choose to do so, the request shall be in writing. Once the request is made, XYZ shall take reasonable steps to fulfill the request.
  3. If a request for restriction or “opt out” has been made, the agency Privacy Officer shall notify the appropriate department within 3 business days of the request.

e)Identification of Donors:

  1. XYZ shall not target donors on the basis of their health status, diagnosis, prior or current services rendered, or any other treatment related information.
  2. XYZ reserves the right to share demographic information (i.e., Name, address or other contact information, age, gender, race, and insurance status) and dates of service, if applicable, as needed and permitted by law with business associates (e.g., Department of Social Services, Office of Mental Health) for the purposes of fundraising and marketing.

f)Maintenance of Authorizations and Acknowledgments:

  1. Marketing & Public Relations: The Marketing Department shall maintain all authorizations and acknowledgements it receives for Marketing and Public Relations purposes.

1) The following contents shall be kept in each file:

a)The original authorization (a copy of the authorization will be given to the client/parent/legal guardian/staff);

b)The written acknowledgement that demonstrates the photograph, audio-visual, and/or PHI was reviewed with the applicable client/family/staff prior to the use of their photograph, audio-visual, and/or PHI ( a copy of the acknowledgment shall be given to the client/parent/legal guardian/staff);

c)A cross reference to other authorizations, if applicable (e.g., other siblings); and

d)The request for restrictions &/or opt out.

2) They shall maintain a tracking log on each authorization & request for restrictions &/or opt out.

3) The following contents shall be captured:

Authorization Log-

a)Name & age of the client/family/staff (age not required for staff);

b)Location of the client (e.g., home, RTC, Fingerlakes) or staff

c)Name of the parent/legal guardian (not required for staff authorizations);

d)Effective Date of the Authorization; and the

e)Expiring Date or Event of Authorization

f)Date that XYZ staff reviewed the authorization with the client/family/staff prior to the authorization activation.

Restriction/Opt Out Log-

a)Name & age of the client/family/staff (age not required for staff);

b)Name of the parent/legal guardian (not required for staff authorizations);

c)Effective Date of the Authorization;

d)Expiring Date or Event of Authorization;

e)Name of Person making request to Restrict or Opt Out;

f)Date of Request;

g)Date of Staff Action;

h)Action Taken; and the

i)Date of Notification to Requestor, client, parent/legal guardian, staff & business associates, if applicable.

  1. Residential & Day Treatment Schools: The client’s school record shall maintain the authorizations it receives for school and educational purposes.
  2. Law Enforcement: The client’s clinical record shall maintain the authorizations it receives for law enforcement purposes.

Please Note: # ii & iii above: If the school or staff handling law enforcement issues receive requests for restrictions or opt out, they will also be required to maintain a log as stated above. A CIS or Privacy Officer shall be contacted for assistance.

g)Notifications/Responses:

  1. Once a request has been made to restrict the use of or to “opt out” altogether, the Marketing/Foundation staff shall respond to the requestor within 30 days.
  2. Each response shall inform the requestor:

a)That we have received their request;

b)The action and/or status of the request; and

c)The date the action takes effect.

XYZ photoADM-6

(2/27/03)ml

I

Insert Agency Name and Address

______

XYZ Agency includes XYZ Children's Center, XYZ Work Scholarship Connection, XYZ Children’s Foundation & Corporation, & XYZ Therapeutic Foster Care Program.

Authorization for Taking and Releasing of Photographs, Audio-Visual Tapes, and Stories Fundraising and Public Relations

RE: Client: / ______/ DOB: / ______/ Unit:
(if applicable) / ______

I hereby authorize XYZ Agency and its affiliates to take photographs, audio-visual tape recordings, and/or use de-identified information of myself and/or my child for the purpose of fundraising stories of the child identified above. I also authorize interviews of myself and/or my child with XYZ Agency and/or (name of other organization/representative. If not applicable, write NA on the line):

______

I understand and agree that these photographs, audio-visual tapes and/or “stories” may be reproduced, published, transmitted, broadcast, or exhibited (e.g., newspaper, brochures, television commercials, billboards, newsletters) by or through XYZ Agency in connection with programs or activities related to publicity or fundraising and/or staff development outside the agency. I also understand that other parents/ guardians/advocates/families may photograph or audio-visual tape school or agency events (e.g., concerts, plays, holiday parties).

This authorization takes effect on: ____/____/____ and expires on ___/___/___ or until the following specific event ends: ______.

I hereby release XYZ Agency , its officers and employees from any liability or claim as a result of the release or publication of information (such as names) if these photographs, audio-visual tapes, or stories are reproduced, published, transmitted, broadcast, or exhibited.

I understand that XYZ Agency may not condition the provision of services/treatment on my signing this authorization, except if the treatment is solely for the purpose of creating protected health information (PHI) to be disclosed to a third party.

I also understand that at any time, I have the option to restrict and/or rescind this authorization. Upon such a decision, I shall notify XYZ Agency ’ Privacy Officer (585) 654-4493 of my request to restrict and/or terminate my authorization. At which time, XYZ Agency shall take reasonable measures to remove my PHI, my child and/or family’s PHI from their fundraising/education activities. If so requested by me, XYZ Agency will also remove me from their list of future fundraising/ educational opportunities.

I give this authorization and release in consideration of, and with full knowledge that Hillside's use of these photographs or audio-visual tapes and information about my child and/or family will be in the interest of advancement of services to youth and families.

Parent or Legal Guardian Signature: ______Date: ______

Parent or Legal Guardian Printed Name: ______Date: ______

Witness Signature: ______Date: ______

ADM-6 (Rev 2/27/03)ml -XYZ

Hillside Children's Center, Crestwood Children’s Center, Hillside Work-Scholarship Connection,

Insert Agency Name and Address

______

XYZ Agency includes XYZ Children's Center, XYZ Work Scholarship Connection, XYZ Children’s Foundation & Corporation, & XYZ Therapeutic Foster Care Program.

Authorization for Taking and Displaying of Photographs and Audio-Visual Tapes Within XYZ Agency Residential & Day Treatment Schools

RE: Client: / ______/ DOB: / ______/ School: / ______

I hereby authorize XYZ Agency and its affiliates to take photographs, audio-visual tape recordings, and/or use de-identified information of my child for the purpose of instructional projects and school-wide. I also authorize interviews of myself and/or my child with XYZ Agency and/or (name of other organization/representative. If not applicable, write NA on the line):

______

I understand and agree that these photographs, audio-visual tapes and/or “stories” shall be taken and displayed within the XYZ educational setting in connection with instructional projects and school-wide activities. Additionally, photographs may be printed in the student, published yearbook. I understand that other parents/guardians/ advocates/families may photograph or videotape school or agency events (e.g., concerts, plays, holiday parties).

This authorization takes effect on: ____/____/____ and expires on ___/___/___ or until the following specific event ends: ______.

I hereby release XYZ Agency, its officers and employees from any liability or claim as a result of display or publication of information (such as names) if these photographs or videotapes are exhibited within the school or published in the school yearbook.

I understand that XYZ Agency may not condition the provision of services/treatment on my signing this authorization, except if the treatment is solely for the purpose of creating protected health information (PHI) to be disclosed to a third party.

I also understand that at any time, I have the option to restrict and/or rescind this authorization. Upon such a decision, I shall notify XYZ Agency Privacy Officer (585) 654-4493 of my request to restrict and/or terminate my authorization. At which time, XYZ Agency shall take reasonable measures to remove my child’s PHI from their publication.