NAME OF CSB DISCLOSURE LOG

Client Name: ______ID:______

DATE/TIME OF REQUEST

/ REQUESTOR NAME and ADDRESS / ITEMS REQUESTED / PURPOSE OF DISCLOSURE(Brief Statement) / REQUEST REVIEWED BY /

ITEMS SENT

/
DATE/ TIME SENT
/

SENDOR

POLICY and PROCEDURE: REQUESTS FOR AN ACCOUTNING OF DISCLOSURE OF HEALTH CARE INFORMATION AND THE USE OF THE DISCLOSURE LOG

POLICY
Individuals have the right to request and receive an accounting of disclosures of protected health information made by the agency for a period of six years prior to the date of the request. (Initially this accounting of disclosures may only be traced back to the initial date of HIPAA enforcement 04142003). This accounting applies to disclosures that are not related to treatment, payment, and health care operations or are not covered by client authorizations.
PROCEDURE
  • [Agency] will provide an accounting of disclosures of an individual’s health information that is not related to treatment, payment and health care operations or is not covered by client signed authorizations for up to six years prior to the date of the individual’s request. (Effective 4/14/03)
  • Examples of disclosures that will be listed on the disclosure log are listed on (Agency’s) Privacy Notice and include:
  1. As required by law (ex: reports required for public health purposes, such as reporting certain contagious diseases)
  2. Judicial and Administrative proceedings (ex: Order from a court or administrative tribunal, or legal counsel to the agency, or Inspector General)
  3. Law Enforcement purposes (ex: reporting of gun shot wounds; limited information requested about suspects, fugitives, material witnesses, missing persons; witnesses criminal conduct on premises)
  4. To avert a serious threat to Health and Safety of another person (ex: in response to a specific threat made by person served to harm another)
  5. Children or incapacitated adults who are victims of abuse, neglect or exploitation
  6. Specialized Government functions
  7. Military Services (ex: in response to appropriate military command to assure the proper execution of the military mission)
  8. National Security and Intelligence activities (ex: in relation to protective services to the President of the United States)
  9. State Department (ex: medical suitability for the purpose of security clearance)
  10. Correctional Facilities (ex: to correctional facility about an inmate)
  11. Workers Compensation to facilitate processing and payment
  12. Coroners and Medical Examiners for identification of a deceased person or to determine cause of death.
  13. To the Department of Health and Human Services in connection with an investigation of us for compliance with federal regulations
  • When a request for an accounting of disclosures of health information is received, it will be acted upon within 15 days. (Code of Virginia 8.01-413)
  • An individual may receive an accounting of disclosures once during any 12-month period for no charge.
  • If an individual requests more than one accounting within the same 12 month period, a reasonable, cost-based fee of $_____ may be charged by [Agency]. The individual will be informed in advance of the fee and provided with an opportunity to modify or withdraw the request for a subsequent accounting in order to avoid or reduce the fee.
  • The accounting for each disclosure includes:
  • The date and time of the requested disclosure
  • The name of the entity or person to the information and their address (if known)
  • The specific items requested
  • A brief statement of the purpose of the disclosure, and a copy of the written request for the disclosure
  • Who within (Agency) reviewed the request for disclosure (Privacy Officer, Supervisor of the Program)
  • Actual items disclosed
  • Date and time items sent
  • Name of individual who made the disclosure
  • If the accounting includes multiple disclosures to the same person/entity for a single purpose, the accounting includes the frequency, number of disclosures and date of the last disclosure made during the accounting period.
  • [Agency] maintains the information that is required to be include in an accounting of protected health information for no less than six years from the date of its creation or the date when it was last in effect, whichever is later.
  • Written accounting that is provided to individuals in response to their requests is maintained for no less than six years from the date of its creation or the date when it was last in effect, whichever is later.
  • [Agency] maintains the titles of the persons/offices responsible for receiving and processing requests for an accounting for a period of no less than six years.
Draft 2/2003