Indirect Treatment Relationship: A relationship between a patient and
healthcare provider in which:
The healthcare provider delivers healthcare directly to the patient based on the
orders of another healthcare provider; and
The healthcare provider typically provides services or product, or reports the
diagnosis or results associated with the healthcare, directly to another
healthcare provider, who provides the services or product or reports to the
Health Information (PHI) means information that is part of an individual’s
health information that identifies the individual or there is a reasonable basis
to believe the information could be used to identify the individual, including
demographic information, and that (i) relates to the past, present or future
physical or mental health or condition of the individual; (ii) relates to the
provision of health care services to the individual; or (iii) relates to the
past, present, or future payment for the provision of health care services to an
individual. This includes PHI which is recorded or transmitted in any
form or medium (verbally, or in writing, or electronically). PHI excludes
health information maintained in educational records covered by the federal
Family Educational Rights Privacy Act and health information about UAMS
employees maintained by UAMS in its role as an employer.
Workforce means for purposes of this Policy, physicians, employees,
volunteers, trainees, and other persons whose conduct, in the performance of
work for UAMS, are under the direct control of UAMS, whether or not they are
paid by UAMS.
Content of the Notice -
Notice of Privacy
conforms to §164.520 of the Health Insurance Portability and Accountability Act.
Distribution and publication of the Notice
- Each UAMS HIPAA covered component will be responsible for making the UAMS
Notice of Privacy Practices
available to its patients in accordance with the HIPAA regulations.
For patients with whom UAMS has a direct treatment relationship,
a. Provide the
Notice to the patient no later than the
date of the first service delivery after April 14, 2003. Make a good faith
effort to obtain the individual's written Acknowledgment that they
received the Notice. Document the reason if the written Acknowledgment
was not obtained.
Post the Notice in a clear and prominent location; and
Make the Notice available at all
service delivery sites.
The Notice will be provided to patients who have an indirect
treatment relationship and are physically present at UAMS. The
Notice will be available upon request to patients not physically
present and who have an indirect treatment relationship at UAMS.
An example of this is: mail-in specimens to the UAMS Clinical Laboratory.
In emergency situations, the provision of the Notice and its
written Acknowledgment may be given as soon as reasonably practicable after
the emergency treatment situation.
Notice will be prominently posted on all UAMS public websites.
Notice will be made available in English and Spanish. Other interpretive
accommodations will be provided upon request. Refer to University Hospital
Interpreters Policy P.S.2.07.
audio version, in Spanish and English, of the
Notice of Privacy Practices and Acknowledgment may be
accessed by dialing (501) 526-7270 or 866-273-3554 (toll free number).
Documentation Requirements: A copy of the Notice and each
subsequent revision will be retained for six years by the UAMS HIPAA Office.
Acknowledgment of Receipt of
By signing this form, you are only agreeing that you
have received a copy of the UAMS Notice of Privacy Practices.
Print Legal Representative’s Name (if applicable)
Legal Representative Signature
If Legal Representative,
authority of Legal Representative _______________________
(such as parent of a minor, court-appointed
guardian, administrator of estate of deceased, attorney-in-fact appointed with
power of attorney, or healthcare proxy)
STAFF USE ONLY
We provided the Notice of Privacy Practices and attempted to obtain written
Acknowledgment but acknowledgment could not be obtained because:
Patient or Legal Representative declined to
sign the Acknowledgment of Receipt.
Other (please specify)____________________________
Printed Name of Employee Completing Form
Signature of Employee Completing
Form UAMS Location