Use and Disclosure of PHI - Governmental Purposes

Category: Privacy

Date: March 2003

Reviewed/Revised: April 2013

Policy

It is the policy of EVMS Medical Group Clinical Departments to provide patient healthcare information to public health authorities or law enforcement agencies as required by law.

Procedure

1. Inform the patient that protected health information may be provided to public health authorities. This may include information to:
   1. Prevent or control a disease, injury or disability.
   2. Report a communicable disease.
   3. Report a birth.
   4. Report a death.
   5. Report child abuse or neglect.
   6. Report adverse effects of food or dietary supplements.
   7. Report defects or problems with a biologic product.
   8. Report defective products to enable product recalls, repairs or replacements.
   9. Follow up with the use of products to comply with the requirements of the Food and Drug Administration.
   10. Investigate a work-related illness or injury.
2. In the event that the EVMS Medical Group Clinical Department believes a patient is a victim of abuse, neglect or domestic violence, protected healthcare information will be provided to a government authority, social service, protective services agency or other agency authorized by law to receive report of such abuse, neglect or domestic violence.
   1. The provider will inform the patient if/when this information will be provided to report the abuse, neglect or domestic violence to an authorized agency.
   2. The patient can refuse to have the abuse, neglect or domestic violence reported.
   3. The EVMS Medical Group Clinical Department can overrule the patient’s decision to not report the abuse, neglect or domestic violence if it is determined that the reporting is necessary to prevent serious harm to the individual or other potential victims.
   4. If the patient is unable to agree to have the information reported about abuse, neglect or domestic violence, a law enforcement or public health official will act upon the information only if it is determined that waiting until the patient agrees to report the information could adversely affect the outcome.
   5. The Clinical Department will not inform a personal representative of the report of abuse, neglect or domestic violence if the hospital believes the personal representative is responsible for the abuse, neglect or other injury.
3. The Clinical Department may provide protected health information to a health oversight agency for the purpose of conducting audits, civil, administrative or criminal investigations, inspections, licensure, disciplinary actions or other activities necessary for the operations of the hospital.
4. The Clinical Department may not provide protected health information if the patient is under investigation or to investigate if the patient qualifies to receive public benefits when the patient’s health status is needed to make the decision about receiving the public benefit.
5. The Clinical Department may provide protected health information in response to a court order. Only the information requested may be provided.
6. The Clinical Department may provide confidential information in response to a subpoena, discovery request or other lawful process only after informing the patient that the confidential information has been requested. The information may be provided if the agency has attempted to reach the patient using the patient’s last known address, if the notice for the information explains the need for the healthcare information, and the time for the patient to raise objections to the law enforcement agency has elapsed.
7. The Clinical Department may provide information about certain types of wounds or other physical injuries upon court order, court-ordered warrant, subpoena, summons, grand jury subpoena, civil investigative demand or other similar process when it is determined that the information is relevant and material to the investigation and that de-identified information could not be used.
8. The Clinical Department may provide protected health information to a law enforcement official for the purpose of identifying, locating a suspect, fugitive, material witness or missing person. This information is limited to:
   1. Name and address
   2. Date and place of birth
   3. Social security number
   4. Blood type and rh factor
   5. Type of injury
   6. Date and time of treatment
   7. Date and time of death, if applicable, and
   8. Adescription of distinguishing physical characteristics, including height, weight, gender, race, hair and eye color, presence or absence of facial hair (beard or moustache), scars and tattoos.
9. EVMS Medical Group Clinical Departments are not permitted to release information about the patient’s DNA, DNA analysis, dental records or samples, typing or analysis of body tissues or fluids.
10. EVMS Medical Group prohibits the law enforcement agency from using the protected health information for purposes other than the reason it was requested and requires the agency to return or destroy the information at the end of the litigation.
11. The Clinical Department may release protected health information about a patient in response to a law enforcement official’s request if the patient is suspected of being a victim of a crime and agrees that the Department may provide the information. If the patient is incapacitated and cannot agree to the release of the information, the Department will provide the information if the information will not be used against the patient, the investigation would be adversely affected by waiting for the patient to agree to the release of the information, or providing the information is in the best interested of the patient.
12. The Department may release protected health information about a patient who has died to a law enforcement official if it is suspected that the death may have resulted from criminal activity.
13. The Department may release protected health information to a law enforcement official if there is evidence of criminal conduct on EVMS Medical Group premises.
14. The Department may release protected health information to a coroner or medical examiner to identify a deceased patient, determine the cause of death or other duties authorized by law.
15. The Department may release protected health information to funeral directors to carry out their duties with respect to the deceased.
16. The Department may release protected health information to organ procurement organizations or other entities for the purpose of facilitating organ, eye or tissue donation or transplantation.
17. The Department may release protected health information if it believes the information will prevent or lessen a serious/imminent threat to the health or safety of a person or the public. This information may be provided to the person(s) who are the target of the threat or for the identification or apprehension of an individual making the threat.
18. The Department may release protected health information to law enforcement officials when it appears that an individual has escaped from a correctional institution or from lawful custody.
19. The Department may release protected health information of Armed Forces personnel to assure the proper execution of the military mission if a notice has appeared in the Federal Register stating the military command authorities and the purposes for the protected healthcare information.
20. The Department may release protected health information to the Department of Veterans Affairs (DVA) of a patient who is a member of the Armed Forces upon separation or discharge from the military service for the purpose of determining eligibility of benefits administered by the Secretary of Veterans Affairs.
21. The Department may release protected health information of foreign Armed Forces personnel to assure the proper execution of the military mission if a notice has appeared in the Federal Register stating the military command authorities and the purposes for the protected healthcare information.
22. The Department may release protected health information to authorized federal officials to conduct intelligence, counter-intelligence or other national security activities authorized by the National Security Act.
23. The Department may release protected health information to authorized federal officials to provide protective services to the President, to foreign heads of state or for the conduct of investigations.
24. The Department may release protected health information to the Department of State to make medical suitability determinations for security clearance or for mandatory service abroad.
25. The Department may release protected health information to a correctional institution or law enforcement official having custody of an inmate to provide healthcare to the person, to ensure the health and safety of the patient or other inmates, to ensure the health and safety of the officers, employees or others at the correctional facility, to ensure the health and safety of those responsible for the transportation of the inmates, to ensure the health and safety of law enforcement on the premises of the facility and to maintain the safety and security of the facility.
26. EVMS Medical Group Departments may release protected health information to comply with laws relating to workers’ compensation or other similar programs that provide benefits for work-related injuries or illness