UAMS ADMINISTRATIVE GUIDE
|SUBJECT:||RELEASE OF PATIENT DIRECTORY INFORMATION|
1. The UAMS workforce should reference the UAMS Notice of Privacy Practices Policy to inform the patients about the information in the Directory and to describe how this information may be disclosed.
2. The UAMS Notice of Privacy Practices Policy will inform patients of their rights to omit some or all of their information for directory purposes.
3. The “Request to be Excluded from the Patient Directory” form must be maintained for patients who object to any or all of their information being included in the Directory, or if UAMS determines that the patient should be excluded. UAMS will “flag” directory listings and other applicable records to indicate exclusions have been requested.
5. Individuals who identify themselves as members of the media will be referred to the UAMS Office of Communications and Marketing.
6. All other requests for Patient Directory information at UAMS Medical Center must be provided via the HBOC Medipac INFO (Information Desk Inquiry) screen, the Patient Information Screen in OSCAR, by another officially approved mechanism, or by calling Patient Information at (501) 686-6416.
7. If the patient is incapacitated or in an emergency treatment situation, UAMS may use or disclose some or all of the information in the Directory provided the disclosure is:
· Consistent with a known, prior expressed preference of the patient; and
· UAMS determines it is in the patient's best interest.
When it becomes practical to do so, UAMS will inform these patients about the uses and disclosures for Directory purposes and offer them the opportunity to decline inclusion in the Directory.
Request to be Excluded from the Patient Directory
If I am a patient at this facility, I understand that the following information in the facility’s Patient Directory is available to any person who asks for me by name:
(1) my name;
(2) my location in the hospital or clinic location; and
(3) a one word statement of my general medical condition (such as good, fair, serious, critical), without any other specific medical information.
I also understand that members of the clergy may receive this information, along with my religious affiliation, even if they do not ask for me by name.
PLEASE COMPLETE ONE OF THE FOLLOWING IF YOU WISH TO RESTRICT THE RELEASE OF INFORMATION ABOUT YOU FROM THE PATIENT DIRECTORY.
[ ] I do not wish to be included in the Patient Directory. I understand that my exclusion from the Patient Directory will keep this facility from releasing my room number or clinic location to florists, friends, and family and from transferring phone calls to my room. OR
[ ] I agree that my
name can be listed in the Patient Directory, but I want to restrict
the release of the following information from the Patient Directory: (check all
[ ] Do not provide my room number or clinic location.
[ ] Do not provide a one word statement of condition (such as fair, serious, critical)
[ ] Do not provide my religious affiliation
I understand that the above restrictions will apply only to this visit or admission, and that I must request restrictions again at future visits if I want any restrictions to be in effect.
Date of admission or clinic visit Signature of patient or representative Today’s date
[ ] Verbal request and the patient or representative was not available to fill out this form.
[ ] If a request to exclude information from the Patient Directory is initiated by UAMS, instead of by the patient or a patient’s representative, check this box and sign/date below. ___________________________________________ UAMS employee making the request Date
[ ] Patient or UAMS request
received and documented in
UAMS Signature Date
EPF Barcode HIPAA