SUBJECT:ACCOUNTING FOR DISCLOSURES

PURPOSE:The organization is required to account for certain disclosures and to provide individuals with an accounting of such disclosures upon request. This policy is designed to provide guidance and to ensure compliance with all applicable laws related to the accounting of disclosures made pursuant to this manual.

POLICY:The organization will establish procedures for the documentation of disclosures of PHI by the organization and the provision of an accounting of such documentation to patients in accordance with 45 CFR 164.528.

  1. For all disclosures of PHI made by the organization, except disclosures of the PHI set forth in paragraph 2, below, the staff member making such disclosure shall document on the Disclosure Log attached as Exhibit O: (i) the date of the disclosure; (ii) the name and, if known, the address of the person to whom the disclosure was made; (iii) a brief description of the PHI disclosed; (iv) a brief description of the purpose of the disclosure; and (v) the initials of the person making the disclosure.
  2. The organization shall not be required to account for the following:
  3. Disclosures to carry out treatment, payment, and health care operations in accordance with Policy No. P-HIPAA-007;
  4. Disclosures to individuals of their own PHI;
  5. Incidental disclosures;
  6. Disclosures made pursuant to an authorization in accordance with Policy No. P-HIPAA-025;
  7. Disclosures for any directory maintained by the organization made pursuant to Policy No. P-HIPAA-008;
  8. Disclosures to persons involved in the patient’s care or other notification purposes made pursuant to Policy No. P-HIPAA-006;
  9. Disclosures for specialized government functions made pursuant to Policy No. P-HIPAA-021;
  10. Disclosures to correctional institutions or law enforcement officials made pursuant to Policy No. P-HIPAA-016;
  11. Disclosures that are part of a limited data set made pursuant to Policy No. P-HIPAA-026; and
  12. Disclosures that occur prior to April 14, 2003.
  13. Upon completion of a Request for Accounting of Disclosures by a patient, attached hereto as Exhibit K, the organization shall provide an accounting of all disclosures of PHI documented in accordance with this policy which occurred during the period requested by the patient, which period shall not exceed six (6) years prior to the date on which the accounting is requested. The accounting shall include all disclosures made to or by business associates of the organization.
  1. The organization may suspend a patient’s right to receive an accounting of disclosures of his or her PHI if a health oversight agency or official provides the organization with a written or oral statement that such an accounting would be reasonably likely to impede the agency’s activities and specifying the time for which such a suspension is required. If the statement is oral, the organization shall document the statement, including the identity of the agency or official making the statement and limit the suspension to no longer than thirty (30) days from the date of the statement unless a written statement complying with this paragraph is submitted during that time.
  1. The organization must respond to any request for an accounting of disclosures within sixty (60) days of such request. The organization may have a one-time extension of up to thirty (30) days to respond to the request provided the individual is notified in writing of the reason for the delay and the date by which the organization will respond.
  1. The organization shall not charge the patient for the first accounting provided in a twelve-month period. For additional accountings provided within that twelve-month period, however, the organization may charge a reasonable, cost-based fee provided it informs the individual in advance of the fee and provides him or her with the opportunity to withdraw his or her request or modify the request in order to reduce the fee.