UAMS ADMINISTRATIVE GUIDE

NUMBER: 3.1.34
DATE: 04/01/03
REVISION: 03/01/04

SECTION: GENERAL ADMINISTRATION
AREA: ADMINISTRATION
SUBJECT: PATIENT INFORMATION RESTRICTION REQUESTS

SCOPE:

UAMS Physicians, Staff, Faculty, Students and Volunteers

POLICY:      

All UAMS patients have the right to request restrictions on the use and disclosure of their Protected Health Information.  UAMS is not required to agree to any restriction request. UAMS will not agree to any request to restrict information which UAMS is required by law to use or disclose.

PROCEDURE:        

A.                Right to Request RestrictionsPatients will be advised by UAMS Notice of Privacy Practices that they have a right to request restrictions on the use and disclosure of their Protected Health Information.  Specifically, patients have the right to request that UAMS restrict:

1.                   Uses or disclosures of PHI about the patient to carry out treatment, payment or health care operations of UAMS; or

2.                   Disclosures made to family and friends involved in the patient’s care.

B.                 Requirements for Requesting RestrictionsThe patient’s request for restrictions must be in writing and must include the following:

1.                   A description of the information that is to be restricted;

2.                   A statement whether the restriction applies to use, disclosure or both; and

3.                   To whom the restrictions will apply.

The form attached to this Policy must be completed and signed by the patient in order to process the request.  The patient’s request must be approved by a UAMS authorized individual.  The patient should be informed that the request, if agreed upon, will apply only to the UAMS clinic or facility with which the patient has submitted the request.  If the patient wishes for restrictions to apply to other clinics or facilities of UAMS involved in the patient’s care,the patient should be informed that he/she must submit the request form to the individual UAMS clinics or facilities.  Although UAMS is not required to inform the patient, UAMS may inform the patient verbally or in writing of a denial of a request submitted in writing and in accordance with this Policy.  If the patient is informed verbally of a denial of a restriction request, this should be documented on the form.  The completed Form should be maintained in the patient’s medical record and a copy sent to the UAMS HIPAA Office, #829.

C.                 Emergency Situations:  If UAMS has agreed to a restriction, UAMS may not use or disclose PHI in violation of the restriction, except that, if the patient is in need of emergency treatment and the restricted PHI is needed to provide the emergency treatment, UAMS may use the restricted PHI, or may disclose such information to a health care provider, to provide the treatment to the patient.

D.                  Ineffective Restrictions:  A restriction agreed to by UAMS is not effective to prevent disclosures to:

1.               Secretary of the United States Department of Health and Human Services to investigate or determine UAMS’ compliance with the HIPAA regulations; or

2.                 Uses or disclosures required by law for:

  1. public health activities;

  2. health oversight activities;

  3. to report abuse, neglect or domestic violence;

  4. judicial and administrative proceedings;

  5. compliance with workers compensation proceedings in which patient has filed a workers compensation claim;

  6. aw enforcement purposes;

  7. to report a crime in an emergency;

  8. coroners and medical examiners;

  9. organ, eye or tissue donation purposes;

  10. circumstances in which UAMS believes in good faith is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or to the public; or

  11. correctional institutions or other law enforcement custodial situations.

3.        Insurance companies or other third party payors for purposes of payment of health care services provided to the patient.

See UAMS Uses and Disclosure of PHI and Medical Record Policy, 3.1.28  for more information.

E.                 Termination of Agreed Restrictions:  UAMS may terminate its agreement to a restriction if:

1.                 the patient agrees to or requests the termination in writing;

2.                 the patient orally agrees to the termination and the oral agreement is documented; or

3.                 UAMS informs the patient that it is terminating its agreement to a restriction, except that such termination is only effective with respect to PHI created or received after UAMS has informed the patient.

UAMS is not required to abide by the “Termination of Agreed Restrictions” requirements when the restrictions do not apply in emergencies as described in Section E of this Policy, or when the restrictions are ineffective under the HIPAA regulations as described in Section D of this Policy.  

 

For a printable version of the form below, please see the Patient Request to Restrict Use/Disclosure of Health Information Word document.
 

Patient label if available or                                                                                      

 _____________________

 Print patient name

_____________________

 and account number            

Patient Request to Restrict Use/Disclosure of Health Information

(to be completed with assistance of clinic/facility manager or other designee)

 

CLINIC/FACILITY NAME:                                                                                                                            

 

I want to request the following restriction on the use or disclosure of my health information:

 

         Describe the information you want restricted:

 

 

         Check whether you want the information restricted from use by UAMS or disclosure outside of UAMS, or both by checking one or both of the boxes that apply to your request:

 

[      ]     Do not use this information within UAMS

 

[      ]     Do not disclose this information outside UAMS

 

         Specify the persons or entities you want this restriction applied to:

 

 

THIS REQUEST WILL APPLY ONLY TO THIS CLINIC/FACILITY.

IF YOU WISH FOR RESTRICTIONS TO APPLY TO ANY OTHER UAMS CLINIC OR FACILITY, PLEASE CONTACT THAT CLINIC/FACILITY AND COMPLETE A RESTRICTION REQUEST FORM.

THIS REQUEST IS SUBJECT TO REVIEW AND MAY NOT BE APPROVED.

__________________________________________                              _____________________

Signature of Patient or Legal Representative                                                    Date

                                                     

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

 

UAMS response to request:     [      ]     agreed to request    [     ]     denied request

 

Informed Patient:         [    ] verbally                [    ] in writing              Date:                                       

 

Comments:                                                                                                                                                      

                                                                                                                                                                       

 

___________________________________                                      ________________________

Signature of UAMS Authorized Personnel                                                                   Date

 

File Original in Patient’s medical record and send a copy to the UAMS HIPAA Office, #829