1. Verification of Identity/Authority:

A. Identity:  In all circumstances, verify the identity of the person to whom you are disclosing PHI, if the person’s identity is not known to you, including the identity of the patient.  Exception:  Patient Directory – If the patient has not opted out of the patient directory, very limited information about the patient may be provided to any person who identifies the patient by name.  See “Patient Directory” Section 9 in this Policy, UAMS Release of Patient Directory Information Policy, 3.1.20, and 3.1.37 Verification of Identity Policy 3.1.37 for more information.

B. Authority:  Except for the circumstance described above under “Patient Authorization” (when patient has signed Authorization form), verify the authority of the person to request a patient’s PHI, or to request that a patient’s PHI be disclosed to someone else, if the authority is not known to you.  A patient has the authority to request disclosures by virtue of being a patient, and therefore, only a patient’s identity must be verified.  Refer to Section 9 in this Policy to see elements of a valid HIPAA Authorization.

C. Patient Authorization Using UAMS Authorization Form:  If a patient has signed a valid HIPAA authorization or approved UAMS Authorization form to disclose his/her PHI to someone else, then you can follow the Authorization.  It is not necessary to verify the authority of the person designated by the patient to receive the information.  If a patient’s legal representative has signed the UAMS Authorization Form, however, the legal representative’s authority must be verified.  See “Disclosures to Patient’s Legal Representative” and “Patient Authorization Form” set forth in this Policy for more information.

D. Minimum Necessary Policy:  All uses and disclosures of PHI must be made in accordance with the UAMS Minimum Necessary Policy, 3.1.25.

 

SECTION 1 – DISCLOSURES TO THE PATIENT – No Patient Authorization Required.

In general, a patient’s PHI may be disclosed to the patient, verbally or in writing, without the requirement of any patient authorization.  If the patient is not known to you, you must verify the identity of the patient prior to disclosing any information.

Subject to the restrictions and procedures stated in this Policy, a patient has the right to inspect or obtain a copy of their medical records, or PHI maintained in a Designated Record Set, except for the following:

 

A. Psychotherapy notes as defined in this Policy;

B. Information compiled in, or for use in, a civil, criminal or administrative action or proceeding; or

C. PHI that is subject to the Clinical Laboratory Improvements Amendments of 1988 (CLIA).

 

See “Patient Request for Access To Or A Copy Of Medical Records” set forth in this Policy for more information.

SECTION 2 – FOR UAMS TREATMENT, PAYMENT AND OPERATIONS – No Patient Authorization Required.

PHI may be used or disclosed without patient authorization for our own Treatment, Payment and Health Care Operations as defined herein.  Such use and disclosure, however, is subject to the requirements of the UAMS Minimum Necessary Policy (limiting the use or disclosure of PHI to the minimum necessary) and the UAMS Patient Restriction Request Policy (allowing the patient to restrict the use or disclosure of PHI in certain circumstances).  The identity and authority of the person requesting or receiving the PHI must be verified.

SECTION 3 – TO ANOTHER HEALTH CARE PROVIDER OR COVERED ENTITY – No Patient Authorization Required.

1.        To Other Health Care Provider or Covered Entity for Treatment or Payment:  UAMS may disclose a patient’s PHI, without patient Authorization, to any other health care provider for the treatment and payment activities of that provider which relate to the patient who is the subject of the PHI disclosed, regardless of whether the health care provider is or is not a Covered Entity.

2.       To Other Health Care Provider or Covered Entity for Operations:  UAMS may disclose PHI, without patient Authorization, to any other provider for health care operations of that provider, regardless of whether the provider is or is not a Covered Entity, only if:

 

A. the provider either has or had a relationship with the individual who is the subject of the PHI being requested; and

B. the PHI pertains to such relationship; and

C. the disclosure is for the purpose of the provider’s health care operations listed in the Definition of “Health Care Operations” described in

     Parts (1) and (2) this policy.

 

3.       To a Provider in Organized Health Care Arrangement:  In addition to the disclosures allowed to other providers or covered entities as described above, if the provider/covered entity participates with UAMS in an Organized Health Care Arrangement (as defined by HIPAA), UAMS also may disclose PHI, without patient authorization, to the provider/covered entity for the purpose of any health care operation activities of the Organized Health Care Arrangement.  

SECTION 4 – PATIENT REQUEST FOR ACCESS TO OR A COPY OF MEDICAL RECORDS -- No Patient Authorization Required

 

          1. General Policy Relating to Patient’s Request for Access To or Copy of  Record: 

A. Subject to the restrictions and procedures stated in this Policy, an adult or emancipated minor patient has the right to inspect or obtain a copy of their medical records, or PHI maintained in a Designated Record Set, except for the following:

a. Psychotherapy Notes as defined in this Policy;

b. Information compiled in, or for use in, a civil, criminal or administrative action or proceeding; or              

c. PHI that is subject to the Clinical Laboratory Improvements Amendments of 1988 (CLIA).

B. Viewing or copying of current admission records while an inpatient: Subject to the requirements of this Policy, nursing staff or clinicians may allow patients to view or have a copy of their records as follows:

 

a.                   Patients may view their current admission records, as long as:

1.1       The physician is notified and approves the viewing; and

1.2       The patient has signed a UAMS Authorization form.  Although the use of the Authorization form is not required for a patient to view his/her own record, it is the preferred method.  UAMS must also accept a written request from the patient, or documentation of such request, and response to the request must be made in the patient’s progress notes.

b.                  Patients may have a copy of their current admission records, as long as a written request from the patient is obtained, and documentation of such request and response to the request is made in the progress notes.  The patient should be referred to Health Information Management/Medical Records Department to process the patient’s request for copies. The physician should be notified before copying current admission records.  The records will be copied according to this Policy and the HIM/Medical Records Department Release of Information policy.

c.                   NOTE:  Physicians and nurses, using their professional judgment, may provide a patient with a copy of any portion of their records, such as diagnostic results, progress notes, or other records, without requiring the patient to obtain the records from HIM/Medical Records Department.  In that event, the physician, nurse or other personnel should document in the patient’s progress notes the patient’s request and the records provided.

C.  Requests for Access/Copy While an Outpatient:  Subject to the requirements of this Policy, if patient requests an outpatient clinic or service area to provide access to or a copy of the patient’s medical record, the clinic or service area may provide access to or a copy of the record to the patient, under the following circumstances:

a.                   The patient is requesting only information from the most recent service or diagnostic reports associated with the most recent service; and

b.                  The patient is requesting information only from that clinical service area; and

c.                   The patient has provided a written request for the records, or the clinic has made a note in the patient’s medical record identifying the records provided to the patient. Instead, refer the patient to Health Information Management/Medical Records Department, or assist the patient with contacting that office for additional records.

Outpatient areas should avoid copying or printing from any protected health information source from a previous date of service or from a different clinic for release to the patient. Instead, refer the patient to Health Information Management/Medical Records Department, or assist the patient with contacting that office for additional records.

All requests for previous information or information from another clinical service should be forwarded to the Health Information Management/Medical Records Department.  Components of UAMS should forward requests to the designated area of their facility.

D.   Never Leave Patient Alone With UAMS Record:  When providing a patient or family member access to the patient’s medical record, a designated UAMS employee must be present at all times to protect the integrity and confidentiality of the information. Items may not be added to or removed from the medical record.

 

E.   Questions Regarding Treatment or Amendment of Record:  All questions regarding treatment must be forwarded to the physician.  If the patient wants to make an amendment to correct information in his/her medical record, an Amendment Request form must be completed in accordance with UAMS Patient’s Request to Amend Medical Records or PHI, 3.1.32.

F.    Viewing or copying of patient’s previous medical records: Refer to Medical Records Department and Written Request Required. If a patient requests access to or a copy of his/her medical records, or PHI maintained in a Designated Record Set, the patient will be referred to Health Information Management/Medical Records Department and the request for such records must be in writing. The records will be copied according to this Policy and the HIM/Medical Records Department Release of Information policy. Requests to review medical records in person require an advance appointment.

          2.Family of Patient Viewing or Having Copy of Medical Record: If the patient is requesting that family or another designee view or have a copy of the patient’s record while patient is an inpatient or outpatient, an Authorization form must be signed by the patient. See the attached Authorization for Access to and Release of Information Form. See also “Disclosures to Spouse/Family/Friends Involved in Patient’s Care” section of this Policy.

         3.Timeliness of Response to Request for Access To or Copy of Record: UAMS will act on a request for access to or a copy of a medical record within thirty (30) days after receipt of the request if the record is held or is accessible on site, or within sixty (60) days if it is not accessible on site. This time limit may be extended for an additional thirty (30) days if UAMS sends the person a written statement of the reason for the delay and the date when the party can have the information. UAMS should date-stamp the first page of any written request or otherwise indicate when the request was received by UAMS. All written requests and authorizations must be stored in the patient’s record. Even if UAMS receives duplicate requests, all such requests must be stored in the patient’s record.

A. If the request is granted, in whole or in part, UAMS will inform the requesting party of acceptance and provide the access requested.

B. If the request is denied, in whole or in part, UAMS will provide a written denial to the patient in accordance with this policy.

 

4. Denial of Access/Copy Without Opportunity to Review: UAMS may deny access to or a copy of PHI without providing an opportunity for the patient or personal representative to review the denial in the following circumstances:

A. The PHI is exempt from right to access as set forth in Section 6A.1 above.
B. An inmate’s request to obtain PHI, if obtaining such information would jeopardize the health, safety, security, custody, or rehabilitation of the inmate or other inmates, or the safety of any officer, employee, or other person at the correctional institution or the person transporting the inmate.
C. The PHI was created or obtained during a research study that involves treatment of the patient and the patient agreed not to access the PHI until the study is concluded.
D. If UAMS received the PHI from someone other than a health care provider and promised to keep the PHI confidential and allowing access would be likely to reveal the source of the information.

5. Denial of Access/Copy with Opportunity to Review: In the following circumstances, UAMS may deny access to or a copy of     PHI. However, the patient has the right to have the denial reviewed by a licensed health care professional designated by UAMS,     who was not involved in the original decision to deny the request.

A. Requests for information that UAMS reasonably believes is likely to cause substantial harm or to endanger the physical safety or life of the patient or another person.
B. Requests made by a personal representative where the access is reasonably likely to cause substantial harm to the patient or another person.

6. Response to Patient if Request to Access/Copy is Denied: UAMS will comply with the following when denying access to PHI:

A. If possible, exclude the parts to which UAMS has grounds to deny access and allow access to the rest of the PHI.
B. Provide a timely written denial to the requesting party containing:
C. The basis for the denial;
D. A statement of the patient’s review rights, including a description of how the patient may exercise such review rights; and
E. A description of how the patient may complain to the hospital as specified in its Notice of Privacy Practices or to the Secretary of DHHS.
F. If UAMS does not maintain the records but knows where the information is maintained, UAMS will inform the patient where to direct the request for access.
G. UAMS will refer any request for a review to the designated licensed health care professional who will, within a reasonable time, determine whether or not to uphold the denial.
H. UAMS will promptly provide written notice of the review decision to the patient or take other action as required.

 

SECTION 5 – DISCLOSURES TO PATIENT’S LEGAL REPRESENTATIVE – No Patient Authorization Required, but Must Be Authorized By Law.

            1. Patient’s Legal Representative:  Except as provided by this Policy, UAMS must treat a patient’s Legal Representative as the patient     for purposes of the use and disclosure of the patient’s PHI.  The following determinations must be made in considering whether a person     is a Legal Representative authorized by law to act on behalf of the patient:

        A.  The person is authorized by law to act on behalf of the patient in connection with the patient’s health care decisions, such as:

a.     Parent of their minor child; - See “Minors” Section of this Policy

b.    Court-appointed Guardian of a minor;

c.    Court-appointed Guardian of an elderly or incapacitated person;

d.     Appointed by the patient to act as their attorney-in-fact in a Durable Power of Attorney with health care rights;

e.      Appointed by the patient in a Health Care Proxy;

f.      A person authorized by Ark. Code Ann. § 20-9-602 to verbally or otherwise consent to treatment/procedures suggested/directed by physician for the following persons of “unsound mind”:

                                                                        1)         adult sibling of the patient of unsound mind; or

                                                                        2)         spouse of the patient of unsound mind; or

                                                                        3)         adult child for parent of unsound mind.

g. Court-appointed Administrator or Executor or Personal Representative of the Estate of a deceased patient. A guardianship or a power of attorney (or any other grant of authority by the patient) are no longer effective upon death. No will is effective until probated. 

h.  For persons who are terminally ill or permanently unconscious – see  Ark. Code Ann. 20-17-202;    

i.   For Incapacitated persons for whom there is no health care proxy or other authority, see to Ark. Code Ann. 20-17-214.

2. Verification of Identity/Authority: UAMS will request verification of the identity of the Legal Representative, if not known, and     the authority of the Legal Representative to act on behalf of the patient, if not known. If no evidence of his/her authority is available     in the record or otherwise, such as a copy of the court order, the Power of Attorney or any other written documentation evidencing    their authority, UAMS will request a copy from the Legal Representative.

3. Do Not Provide PHI if Suspected Harm by the Representative: A provider is not required to treat a person as the Legal or     Personal Representative of the patient for purposes of disclosing PHI if the provider has a reasonable belief that the patient has been     or may be subjected to violence, abuse or neglect by the person acting as a Legal/Personal Representative, or it could endanger the     patient, or it is not in the best interest of the patient.

SECTION 6 – DISCLOSURES TO SPOUSE/FAMILY/FRIENDS INVOLVED IN PATIENT’S CARE – No Patient Authorization, but Special Circumstances Must Exist.

1 Verification of Identity: The identity of the patient and the person receiving the PHI must be verified. In making verification decisions in these particular circumstances, UAMS may rely on the exercise of professional judgment of its staff to determine a person’s identity.

2. When Patient Present (in person or on phone): Can disclose to Spouse, Family or Friends only under the following circumstances:

A. If the spouse, family or friend is identified by the patient; and
B. The spouse, family or friend is involved in the patient’s care; and
C. One of the following circumstances exists:

a. Patient has agreed (verbally on phone or otherwise); or
b. Patient does not object when provided opportunity to do so; or
c. You can reasonably infer from circumstances that the patient does not object (such as when patient     brings family member into examination room); or
d. There is a medical emergency.

PHI disclosed in these circumstances must be limited to PHI that is directly relevant to person’s involvement with the patient’s care or payment; or to notify them of patient’s location, one word statement of general condition, or death.

3. When Patient is NOT Present (in person or on phone), then we may:

A. Disclose (by phone or otherwise) to spouse/family/friends involved in patient’s care PHI that is directly relevant to the person’s involvement with the individual’s health care or payment if we determine that disclosure is in the best interest of the patient.
B. Allow person to pick up filled prescriptions, medical supplies, X-rays or other similar forms of PHI, using professional judgment and experience with common practice to make reasonable inferences of the patient’s best interest in allowing a person to act on behalf of the individual.

4. When Patient Cannot Agree/Object Because of Patient’s Incapacity or an Emergency Circumstance, then we may:

A. Disclose [by phone or otherwise] the PHI permitted for the facility directory (name, location and one word statement of general condition), but only if this is consistent with a prior expressed preference of the patient and it is in the patient’s best interest to do; and
B. Disclose [by phone or otherwise] to spouse/family/friends involved in patient’s care PHI that is directly relevant to the person’s involvement with the individual’s health care or payment if we determine that disclosure is in the best interest of the patient; and
C. Allow person to pick up filled prescriptions, medical supplies, X-rays or other similar forms of PHI, using professional judgment and experience with common practice to make reasonable inferences of the patient’s best interest in allowing a person to act on behalf of the individual.                                                                                          

SECTION 7 – PATIENT AUTHORIZATION FORM.

Except as stated in this Policy and consistent with the requirements of federal and state law, UAMS will not provide access to or disclose PHI without the patient’s Authorization.  In addition, UAMS will verify the identity of a person requesting PHI and the authority of the person to have access to PHI, if the identity or authority of the person is not known to the personnel receiving the request for such information. 

NOTE:  Patient Directory.  If a person is asking for the information in the UAMS  Patient Directory, the person only needs to identify the patient by name, and UAMS may release the location of the patient in our facility, and the patient’s general condition described in a one-word statement, such as good,  fair, serious or critical, unless the patient has asked us not to. Please refer to UAMS Release of Patient Directory Information Policy, 3.1.20.

2. Requirements of Authorization: For an authorization from a patient or the patient’s Legal Representative to be valid, it must be written in plain language, and contain the following elements:

A. A specific description of the information to be used or disclosed.
B. The persons, or class of persons, authorized to make the requested use or disclosure.
C. The name (or other specific identification) of the persons, or class of persons, to whom UAMS may disclose the records.
D. A description of each purpose of the requested use or disclosure.
E. An expiration date or expiration event. 
F. A statement that the person can revoke the authorization in writing, the process for revoking the authorization, and a statement that the person cannot revoke authorization for records already released in reliance upon the authorization.
G. A statement that UAMS will not condition treatment or payment on the whether the individual signs the authorization, unless the authorization is for research purposes, and then UAMS may condition research-related treatment upon the signing of the authorization. 
H. A statement that records or information in the records released might be redisclosed by the person receiving them and will not be covered under the federal privacy laws.
I. Signature of the patient and date; and
J. If the authorization is signed by a Legal Representative of the patient, a description of the Representative’s authority to act for the patient, (e.g., “parent of a minor,” “Court-appointed guardian,” “health care proxy,” “pursuant to appointment under Power of Attorney.”)

3. Authorizations Requested by UAMS: If UAMS requests a written authorization from the patient to release records, the authorization must contain those items in Paragraph A above.

4. Combining Authorizations: The authorization may not be combined with any other document except as follows:

 A patient authorization for use and disclosures created for a research study may be combined with any other type of written permission for the same research study; or
B. A patient authorization for a use or disclosure of Psychotherapy Notes may only be combined with another authorization for a use or disclosure of Psychotherapy Notes.

5. Conditioning: UAMS will not condition provision of treatment or payment on obtaining patient authorization to use or disclose PHI except under the following circumstances:

A. Research related treatment; or
B. Provision of health care solely for the purpose of creating PHI for disclosure to a third party, for example pre-employment physicals.

6. Continuing Effect of Authorization: A valid authorization shall be effective for the release of PHI for 90 days from the date it is signed unless the authorization specifies a different period of time, or the patient or patient’s Legal Representative later revokes the authorization.

7. Patient’s Revocation of Authorization: The patient has the right to revoke/cancel his or her Authorization previously given to UAMS. The revocation must be in writing, signed by the patient, and delivered to the Medical Records Department of the appropriate UAMS clinic or to the UAMS Health Information Management office. The revocation will not apply to records already released in reliance upon the Authorization.

8. Photocopies of Authorization: A photographic copy or facsimile of a signed authorization may be accepted, as long as the authorization otherwise meets the requirements of this Policy.

9. Provide Copy of Authorization to Patient/Patient’s Representative: When patient or patient’s Legal Representative signs an Authorization for Release of Information Form, a copy of the signed form must be provided to the person signing the form.

10. Authorization for Release of Decedent’s Records: An Authorization to release PHI of a deceased person can be signed by the following:

A. The parent of a deceased minor; or
B. A person appointed by a court to act on behalf of the estate of the deceased, such as an Executor or Administrator. If the Authorization is signed by a person stating he or she has been appointed by a court to act on behalf of the estate of the deceased, a copy of the court order is required; or
C. Other persons authorized by law to act on behalf of the deceased individual or the estate of the deceased individual. 
D. (If the request for the release of the records is for the purpose of providing treatment to a surviving relative of the deceased individual, the records may be released to the relative’s physician without an authorization.)

11. Authorization for Unemancipated Minor: Generally - An authorization for release of PHI concerning a minor (under 18 years of age) who is unemancipated (living at home, and dependent on parents for financial support, education, medical care, etc.) can only be given by a parent or legal guardian of the patient

12. Authorization of Unemancipated Minor of Divorced or Separated Parents: If the parents are divorced or legally separated, either parent (who has not had his/her parental rights terminated by the court) may sign the authorization unless a valid court order specifies otherwise.

13. Authorization of Emancipated Minor: An authorization for release of PHI concerning a minor (under 18 years of age) who is emancipated (not living at home and not dependent on parents for support, medical care, education, etc.) can only be given by the patient himself.

14. Authorization by One Standing in Loco Parentis: An authorization for release of PHI concerning a minor (under 18 years of age) who is unemancipated may be given by an adult who stands “in loco parentis” to the minor. (A person standing “in loco parentis” is one who is responsible for providing all support for the minor.)

15. Keep Authorization in Record: The original or a copy of every authorization to release PHI will be maintained as a permanent part of the medical record. 

16. Refusal to Honor Authorization: UAMS may refuse to honor an authorization in the following situations:

A. When there is a question as to the identity or authority of the person requesting release of the records;
B. When there is a doubt that the person requesting the information is the person named in the authorization;
C. If UAMS has knowledge that the person who signed is not of legal age or is incompetent;
D. When there is a question as to the legal guardian of a minor or incompetent patient;
E. When there is a reason to know the patient may not want the authorization honored;
F. When there is any question as to the authenticity of the signature of the patient or person signing on behalf of the patient;
G. When the requirements of this policy have not been met; or
H. If there is a reasonable belief that a minor patient has been abused or neglected and that releasing the record to the personal representative requesting it might endanger the child.

SECTION 8 - DISCLOSURE OF INFORMATION OUTSIDE UAMS FOR PURPOSES UNRELATED TO TREATMENT, PAYMENT AND OPERATIONS.

1. General Rule Concerning Disclosure Outside UAMS: UAMS may not release PHI and other Confidential Information externally unless it is in accordance with UAMS policies and consistent with federal, state and local laws, rules and regulations.
   
   
2. Verification: UAMS will verify the identity and authority of the person requesting PHI.
   
   
3. Disclosure of Information to Attorneys: PHI shall not be released to any attorney (including an attorney of the patient) unless the request is accompanied by a proper Authorization from the patient (or patient’s Legal Representative authorized by law to act on behalf of the patient concerning health care matters), and the authorization must contain the required elements of an Authorization stated above. The request must meet all other applicable requirements of this policy. If the attorney is requesting the records for a family member or any other person claiming to have the authority to act on behalf of the patient, the authority of the person to act on behalf of the patient must be verified in accordance with this Policy.
   
   
4. Disclosure of Information to the News Media: All requests for releases of PHI to the news media should be referred to the UAMS Office of Communications and Marketing.
   
   
5. Disclosure of Information to Patient’s Employer: PHI shall not be released directly to a patient’s employer unless the request is accompanied by a proper Authorization from the patient, and the request meets the applicable requirements of this Policy. If you are providing PHI directly to the patient for the patient to provide to an employer, then the Authorization Form is not required.
   
   
6. Disclosure of Information to Schools: PHI shall not be released to school personnel, teachers, or school nurses unless the request is accompanied by a proper Authorization as required by this Policy, and the request meets the applicable requirements of this Policy. If you are providing PHI directly to the patient for the patient to provide to a school, then the Authorization Form is not required.
   
   
7. Disclosure of Psychotherapy Notes: Psychotherapy notes are separate from and are not a part of a patient’s medical record or contained in a Designated Record Set. The use and disclosure of psychotherapy notes is very limited. Psychotherapy notes may be used only by the originator of the notes to carry out treatment, or by UAMS for its own training programs in which students, trainees, or practitioners in mental health learn under supervision to practice or improve their skills in group, joint, family or individual counseling; or for UAMS to defend itself in a legal action or other proceeding brought by the patient, or by UAMS as required by law. All other uses or disclosures of psychotherapy notes require the patient’s authorization using a separate authorization form. An example of an Authorization for Release of Psychotherapy Notes is attached to this Policy. See definition of “Psychotherapy Notes” stated in this Policy and refer to UAMS Psychotherapy Notes Policy, 3.1.24 for additional information.
   
   
8. Adoption Records: Adoption information and records shall be confidential and shall not be released without a court order authorizing release to a specific person. Any questions pertaining to release of adoption records should be referred to Office of General Counsel.
   
   
9. Medical Records of Adopted Infants: The persons authorized in the Consent to Adoption such as the adoption agency or the adoptive parent’s attorney may have the medical information and medical records of the infant. Refer to the Consent to Adoption to determine who is authorized.

SECTION 9 – REQUIRED BY LAW – No Patient Authorization Required.

UAMS may use or disclose PHI to the extent required by law, with the condition that:
(a) the PHI used or disclosed is limited to the relevant requirements of such law; and (b) the disclosure is made only to the authorities authorized to receive the information.

“Required by law” generally means a requirement in the law that compels an entity to make a use or disclosure of information that is enforceable in a court of law. For example, some state and federal statutes or regulations require hospitals to report certain health information to the Arkansas Department of Health, the Arkansas Department of Human Services, the Arkansas State Medical Board, the Arkansas State Board of Nursing, or the Arkansas Pharmacy Board. 

The following list of reporting requirements stated below is not intended to be all inclusive, but merely to show examples. 

1. Births and Deaths:  Arkansas Department of Health, Division of Vital Records, must receive reports of births and deaths occurring at UAMS, pursuant to Ark. Code Ann. § 20-18-401 and Ark. Code Ann. § 20-18-601, respectively.
   
   
2. Deaths from Suspicious Circumstances, Criminal Conduct or Other: UAMS must notify the county coroner and the chief law enforcement official of the county and town/city in which a death occurred if UAMS has knowledge of the death, and UAMS suspects that the death occurred as a result of violence, criminal conduct or of any of the other circumstances listed in Ark. Code Ann. § 12-12-315.  Also see Section 13 of this Policy for partial list.
   
   
3. Disease and Disease Prevention: Arkansas Department of Health must receive reports of a positive test at UAMS for the presence of conditions or diseases identified by statute such as the reporting of sickle cell anemia, and any case orsuspected case of Reye’s Syndrome.  Immunizations given to persons under 22 years old must be reported to the Arkansas Department of Health.  Ark. Code Ann. §§ 20-15-302, 20-15-401, 20-15-1203.
   
   
4. Sudden Infant Death Syndrome: The County Coroner must receive reports of the sudden death of a child between the ages of one (1) week and one (1) year who appeared in apparent good health, as required by Ark. Code Ann. § 20-15-502.  If the County Coroner is unavailable, the report is made to the County Sheriff.  The County Coroner or County Sheriff reports the death to the Arkansas Department of Health.
   
   
5. Child Maltreatment/Abuse/Neglect: The DHS Arkansas Child Abuse Hotline must receive reports if any health care professional or medical personnel at UAMS has reasonable cause to suspect that a child under 18 years of age has been subjected to maltreatment, abuse, neglect, sexual exploitation or abandonment; and the Arkansas Department of Human Services and Law Enforcement Officials shall have access to medical records, photographs or videotapes relating to the existence or extent of the maltreatment, abuse or neglect.  Ark. Code Ann § 12-12-506 through § 12-12-508.
   
   
6. Abuse of Elderly, Endangered or Impaired Adult: The Arkansas Department of Human Services (including the Office of Long Term Care), the Office of Attorney General, the County Prosecutor, the County Coroner, and the Adult Abuse Hotline are entitled to receive information if any health care professional or employee of UAMS has reasonable cause to suspect the abuse or neglect of an endangered or impaired adult or an adult residing in a long-term care facility and shall have access to the medical records or other information requested in connection with the investigation of suspected abuse or neglect.  Ark. Code Ann. § 5-28-203, § 5-28-204, and § 5-28-209.
   
   
7. Intentional Infliction of Knife or Gunshot Wounds:  The Office of the County Sheriff and the City Police are entitled to receive information in connection with all cases of knife or gunshot wounds treated by UAMS or while in UAMS, if the wounds appear to have been intentionally inflicted.  Ark. Code Ann. § 12-12-602.
   
   
8. Venereal Disease: The Division of Health Maintenance of the Arkansas Department of Health must be notified when a laboratory examination determines that a specimen from a human body yields microscopical, cultural, serological, or other evidence suggestive of a venereal disease.  Ark. Code Ann. § 20-16-501.
   
   
9. HIV:  The Arkansas Department of Health must receive reports of any person determined to have AIDS or to have tested positive for HIV.  Ark. Code Ann. § 20-15-905 and 20-15-906.
   
   
10. U.S. Department of Health and Human Services:  UAMS must disclose PHI to the Secretary of the U.S. Department of Health and Human Services for purposes of investigating or determining UAMS’ compliance with HIPAA regulations.
    
    
11. State Cancer Registry:   UAMS must disclose certain PHI concerning incidents of cancer to the Arkansas Department of Health’s State Cancer Registry.  Ark. Code Ann. § 20-15-201.

The identity and authority of the person to whom the patient’s PHI is being disclosed must be verified, if not known, prior to the disclosure. 

NOTE: For all such disclosures under this Section, see UAMS Accounting for Disclosures Policy, 3.1.26.

SECTION 10 – REPORTING TO AGENCIES or OTHERS AUTHORIZED BY LAW TO RECEIVE THE INFORMATION – No Patient Authorization Required, But Certain Limitations.

UAMS may use or disclose PHI, without patient authorization, when required or allowed to do so by law for the purpose of reporting to governmental agencies or other authorized individuals, with the condition that (a) the PHI disclosed is limited to the relevant requirements of such law; (b) the disclosure is made only to the authorities authorized to receive the information; and (c) the PHI disclosed is limited to the minimum necessary required for the intended use or purpose of the information. The release of PHI under these circumstances does not change the requirement to protect and maintain the confidentiality of the patient’s PHI.

The identity and authority of the person to whom the patient’s PHI is being disclosed must be verified. UAMS Verification of Identity Policy, 3.1.37.

1. Public Health Authorities:  UAMS may disclose PHI to public health authorities authorized by law to receive such information when the disclosure is made in connection with a public health concern, such as for the purpose of preventing or controlling disease, injury, or disability, for the purpose of reporting to the FDA, or to notify persons who may have been exposed to a communicable disease if authorized under state law to do so. 
2. Health Oversight Agencies:  Health oversight agencies are agencies of the state or federal government, or entities acting under a grant of authority or contract with the public agency, which are authorized by law to oversee the health care system or government programs in which health information is necessary to determine eligibility or compliance.  UAMS may disclose PHI to health oversight agencies for health oversight purposes authorized by law, including audits, investigations, inspections, licensure or disciplinary actions, and other activities necessary for appropriate oversight of the health care system. For example, Medicare and Medicaid, State licensure boards, DHHS Office of Inspector General, and DHHS Office for Human Research Protections or other agencies authorized by law to oversee the health care system.
3. Coroners and Medical Examiners: UAMS may disclose PHI to coroners and medical examiners for the purpose of identifying a deceased person, for determining a cause of death, or for coroner or medical examiner to perform other duties authorized by law.
4. Funeral Directors:  UAMS may disclose PHI as needed for the funeral director to carry out their duties.  UAMS may share PHI prior to, and in reasonable anticipation of, the patient’s death.
5. Organ/Eye/Tissue Donation Organizations:  UAMS may use or disclose PHI to an organ procurement organization or entity engaged in the procurement, banking, or transplantation of cadaveric organs, eyes, or tissue for the purpose of facilitating organ, eye or tissue donation and transplantation.
6. Workers’ Compensation:  UAMS may disclose PHI to comply with the laws relating to workers’ compensation or other similar programs that provide benefits for work-related injuries or illness without regard to fault. 

NOTE: For all such disclosures under this Section, see UAMS Accounting for Disclosures Policy, 3.1.26.

SECTION 11 - COURT ORDERS, WARRANTS AND GRAND JURY SUBPOENAS – No Patient Authorization Required.

1. UAMS may disclose PHI, without patient authorization, as directed by the following:

   A. a court order;
   B. a court-ordered warrant; or
   C. a grand jury subpoena.

2. The PHI disclosed must be limited to the PHI described in and required by the order, warrant or grand jury subpoena.
3. In addition, the PHI must be disclosed only to those persons identified in the order, warrant or grand jury subpoena as persons directed to receive the information.

NOTE:  For all such disclosures under this Section, see UAMS Accounting for Disclosures Policy, 3.1.26

SECTION 12 – SUBPOENAS and DISCOVERY REQUESTS FROM PARTIES IN LITIGATION – Patient Authorization, Court Order, or Written Assurances Required.

1. General.  This Section covers subpoenas and discovery requests from parties in litigation:  This Section does not cover     subpoenas from a Grand Jury or from Law Enforcement.  UAMS may disclose PHI in response to a valid subpoena or in response     to a discovery request by parties in litigation only if UAMS also receives any one of the following:

A. An Authorization signed by the patient or patient’s Legal Representative. 

a. The Authorization must authorize release of the records described in the   subpoena or include a     description broad enough to encompass the records described in the subpoena.

b. The Authorization must authorize release of the records to the person or persons identified in the     subpoena.

c. The Authorization must be a HIPAA compliant Authorization containing the elements described in this     Policy.

d. A patient’s attorney is not the patient’s “Legal Representative” for purposes of signing an Authorization.      If the Authorization is not signed by the patient, it must be signed by the patient’s “Legal Representative”     who is a person authorized by law to act on behalf of the patient.  For example, a court-appointed     guardian, a person designated as the patient’s attorney-in-fact in a power of attorney, or the parent of     an unemancipated minor. 

B. A court order, or an order of an administrative tribunal such as the Workers’        Compensation Commission. 

C. Written assurances that patient was notified of the subpoena for the patient’s records, and the patient does not object      to the production of the records, or the patient’s objections were overruled by the court.  To provide such written     assurances, the party seeking the patient’s records by subpoena must submit a written statement and documentation to     UAMS showing that:

a. reasonable efforts have been made by such party to ensure that the patient has been notified of the     subpoena for the patient’s records;
b. the notice to the patient included sufficient information about the litigation or proceeding to permit the     patient or patient’s attorney to file objections with the court or administrative tribunal;
c. the time for filing objections has elapsed; and
d. no objections were filed, or if objections were filed, the court or administrative      tribunal ordered the    disclosure, and a copy of the order should be provided.

These written assurances may occur in stages.  For example, UAMS may first receive the subpoena, along with documentation showing that a copy of the subpoena was provided to the patient or the patient’s attorney.  After the time for filing objections has passed, UAMS may later receive the written assurance that the time for filing objections has passed and the patient did not object.

2. Subpoena Without Authorization, Court Order, or Written Assurances:  If a subpoena for patient’s PHI does not include any     other authority for releasing the records, such as the patient’s Authorization, a court order, or the written assurances described     above, UAMS is not authorized to release the records.  UAMS should undertake reasonable efforts to inform the party seeking the     records, prior to the date of production stated in the subpoena if possible, that UAMS is not authorized to release the records     without the required Authorization, court order, or written assurances.

NOTE: If no signed patient Authorization (HIPAA-compliant) and for all such disclosures under this Section, see UAMS Accounting for Disclosures Policy, 3.1.26.

SECTION 13 – SUBPOENAS FROM LAW ENFORCEMENT OFFICIALS.
No Patient Authorization Required, But Certain Limitations.

1. General:  UAMS may disclose PHI to law enforcement officials in response to a valid subpoena, Investigative Demand (which is usually headed “Investigative Demand”), or similar process authorized by law, as long as: (a) The information requested is relevant and material to a legitimate law enforcement inquiry; (b) The request is specific and limited in scope to the extent reasonably practicable in light of the purpose from which the information is sought; and (c) de-identified information could not reasonably be used.
   
   
2. Law Enforcement Official: Law Enforcement Official means an officer or employee of any agency or authority of the United States, a State, a territory, a political subdivision of a State or territory, or an Indian tribe, who is empowered by law to: (1) Investigate or conduct an official inquiry into a potential violation of law; or (2) Prosecute or otherwise conduct a criminal, civil, or administrative proceeding arising from an alleged violation of law.
   
   
3. This would include subpoenas from the Arkansas Office of Attorney General, the Prosecuting Attorney’s Office, the FBI, and the police. 

NOTE: For all such disclosures under this Section, see UAMS Accounting for Disclosures Policy, 3.1.26.

SECTION 14 – LAW ENFORCEMENT GENERALLY (Without Court Order or Warrant, Subpoena, or Other Legal Process) – No Patient Authorization Required, But Certain Limitations.

1. Disclosures for Identification and Location of Suspect, Fugitive, Material Witness or Missing Person: 

A. PHI Allowed to be Disclosed:  In response to law enforcement’s request or notice for information to     identify or locate a suspect, fugitive, material witness or missing person, UAMS may disclose the     following information only:

a. name and address;
b. date and place of birth;
c. Social Security Number;
d. ABO blood type and rh factor;
e. type of injury;   
f. date and time of treatment;
g. date and time of death, if applicable; and
h. description of distinguishing physical characteristics, such as weight, height, gender, race,     hair/eye color, presence or absence of facial hair, scars, tattoos.

B. Disclosure Not Allowed:  UAMS may not disclose the following information in response to law enforcement’s request or notice for information to identify or locate a suspect, fugitive, material  witness or missing person:

a. DNA or DNA analysis;
b. dental records;
c. typing, samples or analysis of body fluids or tissue.

2. To Prevent or Lessen Serious and Imminent Threat to Health or Safety: 

A. Disclosures to Law Enforcement:  UAMS may, consistent with the law and standards of ethical      conduct, use or disclose PHI to a Law Enforcement Official, without patient authorization or other      authority, if UAMS believes in good faith that the use or disclosure is:

a.  necessary to prevent or lessen a serious and imminent threat to the health or safety of any      person or the public;
b. and the disclosure is (i) to persons reasonably able to prevent or lessen the threat, such as     law enforcement; or (ii) the disclosure is necessary for law enforcement to identify or     apprehend an individual because of a statement made by an individual admitting     participation in a violent crime that the covered entity reasonably believes may have     caused serious physical harm to the victim or where it appears from the circumstances that     the individual has escaped from a correction institution or from lawful custody.

B. Disclosures to Others:  UAMS may, consistent with the law and standards of ethical conduct, use or     disclose PHI, without patient authorization or other authority, if UAMS believes in good faith that the     use or disclosure is:

a.  necessary to prevent or lessen a serious and imminent threat to the health or safety of a     person or the public;
b.  and the disclosure is (i) to persons reasonably able to prevent or lessen the threat,      including the target of the threat; or (ii) the disclosure is necessary for law enforcement to      identify or apprehend an individual because of a statement made by an individual      admitting participation in a violent crime that the covered entity reasonably believes may      have caused serious physical harm to the victim or where it appears from the      circumstances that the individual has escaped from a correctional institution or from lawful      custody.

3. To Report a Crime on UAMS Property:  UAMS may disclose PHI to a Law Enforcement Official if UAMS     believes in good faith that the PHI disclosed constitutes evidence of criminal conduct that occurred on the premises of     UAMS.

4. Deaths:  UAMS must notify the county coroner, the chief law enforcement official of the county, and the chief law     enforcement official of the town/city where the death occurred if UAMS has knowledge of the death and any of the     following circumstances appear to exist:

A. death was caused by violence, homicide, suicide or appears to be accidental;
B. death resulted from presence of drugs or poisons in the body;
C. death resulted from drowning;
D. death resulted from motor vehicle accident or body was found in or near a roadway or railroad;
E. death occurred in hospital and no previous medical history to explain the   death;
F. death occurred while person in policy custody, a jail, or penal institution;
G. death resulted from fire or explosion;
H. death of minor indicated child abuse prior to death;
I. death of minor and no prior medical history to explain the death;
J. human skeletal remains were recovered or unidentified deceased person  was discovered;
K. death was due to criminal abortion;
L. manner of death was from other than natural causes;
M. death was sudden and unexplained;
N. death occurred at work site; or
O. death occurred in the home.

See Arkansas Code Ann. 12-12-315 for additional examples.

5. Suspected Child Abuse or Neglect:  If there is reasonable cause to suspect that a child has been subjected to     abuse/neglect or has died as a result of abuse/neglect, or if a child is observed being subjected to conditions or     circumstances that would reasonably result in child abuse/neglect, UAMS must use and disclose PHI for purposes of     contacting the Arkansas Child Abuse Hotline and reporting to the authorities authorized by law to receive such     information, such as the Arkansas Department of Human Services and other Law Enforcement Officials investigating     the suspected abuse/neglect.

6. Abuse of Elderly, Endangered or Impaired Adult: UAMS must use and disclose PHI to the Arkansas     Department of Human Services (including the Office of Long Term Care), the Office of Attorney General, the County     Prosecutor, the County Coroner, or the Adult Abuse Hotline if UAMS has reasonable cause to suspect the abuse or     neglect of an endangered or impaired adult or an adult residing in a long-term care facility and these agencies may     have access to the medical records or other information requested in connection with the investigation of suspected     abuse or neglect. 

A. Informing the victim is required:  If UAMS makes a disclosure in the case of abuse of elderly,     endangered or impaired adults, UAMS must promptly inform the patient/victim that such a report has     been or will be made.  See exceptions below.

B. You do not have to inform the victim in certain limited circumstances:  Informing the patient/victim that     UAMS has or will report the suspected abuse/domestic violence is not required if:  (1) UAMS believes,     in the exercise of professional judgment, that informing the individual would place the individual at risk of     serious harm; or (2) UAMS would be informing a Legal Representative of the patient who is authorized     by law to act on behalf of the patient (such as a court-appointed guardian), and UAMS reasonably     believes the Legal Representative is responsible for the abuse, neglect, or other injury, and that informing     such person would not be in the best interests of the patient/victim.

7. Other Law Enforcement Purposes:  PHI also may be used and disclosed without patient authorization or     permission in the following circumstances:

A. For specialized government activities including military and veterans’ activities, national security and intelligence      activities and protective services for the President and others. 

B. To correctional institutions and law enforcement officials about an individual who is an inmate or is in their      lawful custody if necessary for the health and safety of the individual, other inmates, officers or other      employees at the correctional institution, or persons responsible for the inmate’s transportation or otherwise      for the administration and maintenance of the safety, security and good order of the correctional institution

C. If emergency medical care is provided, other than on the premises of UAMS, and disclosure of PHI appears      necessary to alert law enforcement to: (a) the commission and nature of a crime; (b) the location of the crime     or the victims of the crime; or (c) the identity, description and location of the perpetrator of the crime. 

NOTE:  For all such disclosures under this Section, see UAMS Accounting for Disclosures Policy, 3.1.26

SECTION 15 – ADULT VICTIMS OF ABUSE, NEGLECT or DOMESTIC VIOLENCE – Reporting to Authorities Requires Patient Consent.

1. Victim’s Consent Required: Except for the circumstances listed below in “Exceptions,” UAMS must obtain the written or verbal consent of a patient (age 18 or older) whom UAMS reasonably believes to be a victim of abuse or domestic violence before UAMS can report the suspected abuse or domestic violence to a government authority authorized by law to receive such reports, such as the police, DHS, a social services agency or a protective services agency.   (If the government authority authorized by law to receive such reports presents a subpoena, court order or warrant, then refer to the various Sections in this policy regarding subpoenas, court orders and warrants, whichever is applicable.)

The consent may be written or verbal:  An Authorization form is not required, but may be used.  Once consent is given, the medical evidence relevant to the victim’s injuries and the alleged crime may be disclosed.  

2. Exceptions:  Victim consent is not required for:

A. Reports of abuse/neglect of a child under 18.

B. Reports of abuse/neglect of the elderly or an impaired or endangered adult.

C. Disclosures of certain limited information to Law Enforcement to identify or locate a suspect, fugitive,      material witness or missing person.  See section of this Policy entitled “Law Enforcement Generally.”

D. All other disclosures required by law and to the extent that the disclosure complies with and is limited to      the relevant requirements of such law (such as reporting deaths, intentional inflicting of gunshot or knife      wounds, and other reporting requirements).  See section of this Policy entitled “Law Enforcement      Generally” and see “Required by Law” section for disclosures required by law.

E. Disclosures made pursuant to a court order, warrant or other similar legal process enforceable in a court     or law. 

3. If Victim Incapacitated:  If UAMS is unable to obtain the victim’s agreement because the victim is incapacitated,     UAMS can disclose the victim’s PHI only if all of the elements of “Circumstances ONE” or “Circumstances TWO”     exist:

Circumstances ONE

1.         The disclosure is expressly permitted by statute or regulation; and
2.         The Law Enforcement Official represents that (a) such information is needed to determine whether a violation of             law by a person other than the victim has occurred, and (b) such information is not intended to be used against             the victim; and
3.         The Law Enforcement Official represents that immediate law enforcement activity that depends upon the            disclosure would be materially and adversely affected by waiting until the individual is able to agree to the            disclosure.

OR

Circumstances TWO:

1.         The disclosure is expressly permitted by statute or regulation; and
2.         UAMS workforce members involved believe that, in the exercise of professional judgment, the disclosure is             necessary to prevent serious harm to the individual or other potential victims.

4. When Informing the Victim of Disclosure/Report is Required:

A. Informing the victim is required:  If UAMS makes a disclosure with the consent of the patient/victim, as     described above, or in the case of abuse of elderly, endangered or impaired adults where consent is not     required, UAMS must promptly inform the patient/victim that such a report has been or will be made.      See exceptions below.

B. You do not have to inform the victim in certain limited circumstances:  Informing the patient/victim that     UAMS has or will report the suspected abuse/domestic violence is not required if:  (1) UAMS believes,     in the exercise of professional judgment, that informing the individual would place the individual at risk of     serious harm; or (2) UAMS would be informing a Legal Representative of the patient who is authorized     by law to act on behalf of the patient (such as a court-appointed guardian), and UAMS reasonably     believes the Legal Representative is responsible for the abuse, neglect, or other injury, and that informing     such person would not be in the best interests of the patient/victim.

NOTE:  If no signed patient Authorization (HIPAA-compliant) and for all such disclosures under this Section, see UAMS Accounting for Disclosures Policy, 3.1.26.

SECTION 16 -- ADULT VICTIMS OF RAPE, ATTEMPTED RAPE, SEXUAL ASSAULT OR INCEST – Reporting to Authorities Requires Patient Consent. 

1. UAMS will follow the requirements of Arkansas law, Ark. Code Ann. 12-12-401 through 12-12-405 regarding treatment of victims of rape, attempted rape, sexual assault or incest.
2. If an  adult patient, age 18 years or older, is presented for treatment as a victim of rape, attempted rape, any other type of sexual assault, or incest, the adult patient shall make the decision of whether the incident will be reported to a law enforcement agency.  If consent is given to UAMS to contact law enforcement on behalf of the victim, the consent may be given verbally.  A HIPAA-compliant authorization is not required, but may be used.
3. UAMS may not require an adult victim to report the incident in order to receive medical treatment.  Evidence will be collected only with the permission of the victim.  However, permission to collect such evidence shall not be required in instances where the victim is unconscious, mentally incapable of consent or intoxicated.  Once evidence is collected, it will be provided to law enforcement with the permission of the victim.

See UAMS Policy ML.1.08 regarding sexual assault of adult.

NOTE:  If no signed patient Authorization (HIPAA-compliant) and for all such disclosures under this Section, see UAMS Accounting for Disclosures Policy, 3.1.26.

SECTION 17 – SUBSTANCE ABUSE/TREATMENT INFORMATION – Patient Authorization Requiring Using Substance Abuse Treatment Form.

1. Patient Authorization Required:  For patients of the UAMS Substance Abuse Treatment Center or any other UAMS substance abuse treatment program, the patient’s signed Authorization must be obtained before UAMS can disclose any PHI relating to the diagnosis, prognosis, treatment, or referral for treatment in relation to substance abuse (drug or alcohol), including any information which would identify the person as being a patient in such a program, or acknowledgment or confirmation that the person is or was a patient in such a program.
    
2. Access the UAMS Substance Abuse Treatment Authorization form.
    
3. Exceptions:  An authorization signed by the patient is not required in very limited circumstances, such as pursuant to a court order directing the disclosure of information or records specifically relating to substance abuse.  Consult the UA Office of General Counsel for further information in response to a request or subpoena for such information in the absence of a court order or patient Authorization.

SECTION 18.  MINORS.

1. Release of Minors’ PHI to Minors’ Parents:   Generally, the parent of a dependent child under the age of 18 is entitled to all PHI concerning their minor child, regardless of whether the parents are divorced.  A divorced parent who does not have custody of the minor child is still the minor’s parent, and is entitled to all PHI concerning their minor child.  See exceptions below.
   
   
2. Release of Minors’ PHI to Minors’ “Legal Representative:”  The “Legal Representative” of a child is one who has legal authority to act on behalf of the child, including the authority to make health care decisions for the child.   Examples are (1) the parent; (2) a court-appointed Guardian; (3) a person legally acting as a parent (“in loco parentis” – the person has physical custody and supervision of the child, and the child lives with and is supported by the person); or (4) any other court order providing the person with legal custody or the legal authority to act on behalf of the child.
   
   
3. Exceptions to Providing PHI to Parent or Legal Representative of Minor Child:   UAMS is not required to provide a person who has authority to act on behalf of a minor with the PHI of the minor in the following circumstances:

   A. Court Order:  A court order terminates the parental rights of the parent over the minor child or children.       Issues relating to custody do not apply.  The court order must specifically terminate the parent’s rights. 

   B. Not in Best Interest of Child:  UAMS has a reasonable belief that the child has been or may be subjected      to domestic violence, abuse or neglect by such person, or if UAMS has a reasonable belief that the person      may cause physical or emotional harm to the child, or if UAMS determines in the exercise of professional      judgment that it is not in the best interest of the child to release the information.

   C. Biological Father of Child Born Out of Wedlock:  The request for information is by the biological father of      a child born out of wedlock, who does not have physical custody of the child, and who is not married to the      mother at the time of the request.  The biological father must provide a copy of a court order providing the      father with legal custody, parental rights or some other authority to act on behalf of the child or to receive      information. 

   D. Venereal Disease:  The minor has consented to their own treatment for a known or suspected venereal      disease.  However, the treating physician may release the information to the minors’ parents or Legal      Representatives if the treating physician determines that the information should be released, even over the      objections of the minor.  This does not prohibit the confidential reporting of a confirmed case of a venereal      disease to the Arkansas Department of Health as required under Arkansas law.  All records of such      information concerning the minor’s known or suspected venereal disease should be maintained in a manner      that the user can determine immediately and easily that the records are confidential and are not to be released      with the rest of the medical record.

SECTION 19.  EMERGENCY CIRCUMSTANCES – No Patient Authorization Required. 

NOTE:  For purposes of this Section, when “good faith” is required, “good faith” is presumed to exist if it is based upon the actual knowledge of UAMS or is based upon UAMS’ reliance on a credible representation by a person with apparent knowledge or authority.

1. To Prevent or Lessen Serious and Imminent Threat to Health or Safety:    UAMS may, consistent with the law and     standards of ethical conduct, use or disclose PHI if UAMS believes in good faith that the use or disclosure is necessary to prevent     or lessen a serious and imminent threat to the health or safety of any person or the public in general; and the disclosure is to persons     reasonably able to prevent or lessen the threat, such as to law enforcement or to the target of the threat or to others reasonably able     to prevent or lessen the threat.

2. Admission by Patient of Participation in Violent Crime: UAMS may, consistent with the law and standards of ethical conduct,     use or disclose certain PHI to law enforcement authorities if UAMS believes in good faith that the use or disclosure is necessary for     law enforcement authorities to identify or apprehend an individual because of a statement made by an individual admitting     participation in a violent crime that UAMS reasonably believes may have caused serious physical harm to the victim.  (See     “Exceptions” listed below.)

A. Limited PHI to be Used/Disclosed:  In such circumstances where there has been an admission by a patient as     described above, UAMS may disclose to law enforcement authorities the following information concerning the patient:

a. name and address;
b. date and place of birth;
c. Social Security Number;
d. ABO blood type and rh factor;
e. type of injury;
f. date and time of treatment;
g. date and time of death, if applicable; and
h. description of distinguishing physical characteristics, such as weight, height,          gender, race, hair/eye color, presence or absence of facial hair, scars, tattoo.

B. DNA or DNA analysis, dental records, typing, samples or analysis of body fluids or tissue, or any other PHI may not be disclosed without a court order or warrant or other legal process.

C. Exceptions -- Use/Disclosure Prohibited:  Such a use or disclosure may not be made if the admission of the patient is learned by UAMS (1) in the course of treatment to affect the propensity to commit the criminal conduct that is the basis for the disclosure, (2) in counseling of therapy of the patient; or (3) through a request by the patient to initiate or to be referred for the treatment, counseling, or therapy to affect the propensity to commit the criminal conduct that is the basis for the disclosure. 

3. To Identify or Apprehend Escaped Prisoner:   UAMS may, consistent with the law and standards of ethical conduct, use or     disclose PHI to law enforcement authorities if UAMS believes in good faith that the use or disclosure is necessary for law     enforcement authorities to identify or apprehend an individual where it appears from the circumstances that the individual has     escaped from a correctional institution or from lawful custody.

4. Medical Emergencies:  UAMS may disclose PHI to a person who is the spouse, family or friend involved in the patient’s care,     without patient’s consent or Authorization, in the event of a medical emergency.

SECTION 20 – PATIENT REQUEST TO AMEND RECORD.

1. A patient has the right to request UAMS to amend his or her PHI maintained in the Designated Record Set.  UAMS is not required to agree to all requests by patients to amend their records. Requests to amend will be referred to the Release of Information Office in Health Information Management/Medical Records Department and processed in accordance with the UAMS Patient Request to Amend the Medical Record Policy, 3.1.32.

SECTION 21- COSTS OF OBTAINING COPIES OF MEDICAL RECORDS.

1. UAMS may charge a reasonable, cost-based fee for copies of medical records that includes the cost of copying, cost of supplies and labor of copying, and postage, when the patient has requested the copy be mailed.  UAMS will not charge more than is allowed by law and pursuant to Ark. Code Ann. § 16-46-106.  

          
SECTION 22 – SANCTIONS/DISCIPLINARY ACTION.

1. UAMS workforce who engage in activity in violation of this Policy may be subject to disciplinary action, up to and including termination of employment or relationship with UAMS.

 

 

 

 

 

 

 

SIGNATURE: ________________________________  DATE: _________________________

       

 

 

 

Place Patient Label Here or
Print Patient Name
Account Number

                                                                                                                         Authorization for Release of Information from UAMS

                   

1.       I,                                                                                                                                                    , hereby authorize UAMS to release to:

   

         Name                                                                                                             Phone                                                     Fax