UAMS ADMINISTRATIVE GUIDE

NUMBER: 3.1.35
DATE: 04/01/03
REVISION:3/1/2004

SECTION: GENERAL ADMINISTRATION
AREA: ADMINISTRATION
SUBJECT: POLICY ON USE OF PHI FOR FUNDRAISING

SCOPE 

UAMS physicians, employees, volunteers, trainees, and other persons whose conduct, in  the performance of work for UAMS, is under the direct control of UAMS, whether or not they are paid by UAMS.

PURPOSE

To establish guidelines and restrictions for the use and disclosure of Protected Health Information in connection with all UAMS fundraising activities.

DEFINITIONS 

For purposes of this policy, the following definitions apply:

Demographic Information shall be limited to the following types of information: (a) the patient’s name, address, and other contact information; (b) age; (c) gender; and (d) insurance status.

Fundraising means any activity relating to the efforts of raising funds for the institution of UAMS and its related healthcare facilities.

Protected 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.

POLICY 

UAMS may not use or disclose a patient’s Protected Health Information (PHI) for Fundraising purposes except as allowed by federal and state law, including the Federal HIPAA Privacy Regulations.  UAMS will include an opt-out provision in its Fundraising materials to instruct the recipient on how to opt out of receiving future communications relating to Fundraising.

PROCEDURES

A.        Information Which Can Be Used/Disclosed for Fundraising:  UAMS may use, or disclose to a business associate or to an institutionally related foundation, the following information about the patient for the purpose of raising funds for the benefit of UAMS, without the patient’s prior authorization or consent:

UAMS may also use the following information for Fundraising purposes: 

B.        Authorization Required for Use/Disclosure of PHI for FundraisingExcept for the information listed above, no other PHI may be used or disclosed by UAMS for Fundraising purposes, without the patient’s signed authorization.  The authorization must be an approved UAMS Authorization form allowing the use or disclosure of PHI for fundraising purposes.

Information about the department in which the patient received services also cannot be used or disclosed for Fundraising purposes without the patient’s prior authorization, if that information would reveal or could reveal the patient’s treatment, diagnosis, or nature of healthcare services.  For example, UAMS may not use or disclose for Fundraising purposes the fact that the patient received services from the Department of Psychiatry, the Department of Obstetrics, or the Department of Radiation Oncology. 

Examples of PHI which cannot be used or disclosed for Fundraising purposes:

-           Department of Psychiatry
-           Department of Obstetrics
-           Department of Radiation Oncology

While UAMS may undertake any Fundraising activities targeted for a specific department or type of illness, UAMS may not use or disclose a patient’s PHI to do so (other than as described above in “Information Which Can Be Used/Disclosed for Fundraising”).

C.        Opt-Out Provision in Fundraising Materials UAMS will include in all Fundraising materials instructions on how the individual may opt out of receiving any future communications relating to Fundraising.  An example of such language would be:  “Please write to us at our address if you wish to opt out of future development mailings,” and the address information would be included. UAMS must make reasonable efforts to ensure that individuals who decide to opt out of receiving Fundraising communications are not sent such communications. 

D.        Business Associate Agreement:  UAMS will enter into an appropriate Business Associate Agreement pursuant to the UAMS Business Associate Policy, 3.1.33  prior to disclosing any PHI (including the Demographic Information and dates of healthcare services described above) to an outside consultant or outside entity for Fundraising activities on behalf of UAMS.  An institutionally related foundation to whom UAMS discloses PHI for fundraising activities on behalf of UAMS is not considered a “Business Associate” for purposes of this Policy.