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    HIPAA Privacy Regulations: Uses and Disclosures Requiring an Opportunity for the Individual to Agree or Object: Uses and Disclosures for Involvement in the Individual's Care and Notification Purposes - § 164.510(b)

    As Contained in the HHS HIPAA Privacy Rules

    HHS Guidance: HIPAA and Same Sex Marriage: Understanding Spouse, Family Member and Marriage in the Privacy Rule

    HHS Guidance: HIPAA Privacy in Emergency Situations

    HHS Guidance: Sharing of Information Related to Mental Health

     

    HHS Regulations as Added by the January 2013 Amendments
    Uses and Disclosures Requiring an Opportunity for the Individual to Agree or Object: Uses and Disclosures for Involvement in the Individual's Care and Notification Purposes - § 164.510(b)

     

    (b) Standard: Uses and disclosures for involvement in the individual's care and notification purposes—(1) Permitted uses and disclosures. (i) A covered entity may, in accordance with paragraphs (b)(2), (b)(3), or (b)(5) of this section, disclose to a family member, other relative, or a close personal friend of the individual, or any other person identified by the individual, the protected health information directly relevant to such person's involvement with the individual's health care or payment related to the individual's health care.

    (ii) A covered entity may use or disclose protected health information to notify, or assist in the notification of (including identifying or locating), a family member, a personal representative of the individual, or another person responsible for the care of the individual of the individual's location, general condition, or death. Any such use or disclosure of protected health information for such notification purposes must be in accordance with paragraphs (b)(2), (b)(3), (b)(4), or (b)(5) of this section, as applicable.

    (2) Uses and disclosures with the individual present. If the individual is present for, or otherwise available prior to, a use or disclosure permitted by paragraph (b)(1) of this section and has the capacity to make health care decisions, the covered entity may use or disclose the protected health information if it:

    (i) Obtains the individual's agreement;

    (ii) Provides the individual with the opportunity to object to the disclosure, and the individual does not express an objection; or

    (iii) Reasonably infers from the circumstances, based on the exercise of professional judgment, that the individual does not object to the disclosure.

    (3) Limited uses and disclosures when the individual is not present. If the individual is not present, or the opportunity to agree or object to the use or disclosure cannot practicably be provided because of the individual's incapacity or an emergency circumstance, the covered entity may, in the exercise of professional judgment, determine whether the disclosure is in the best interests of the individual and, if so, disclose only the protected health information that is directly relevant to the person's involvement with the individual's care or payment related to the individual's health care or needed for notification purposes. A covered entity may use professional judgment and its experience with common practice to make reasonable inferences of the individual's best interest in allowing a person to act on behalf of the individual to pick up filled prescriptions, medical supplies, X-rays, or other similar forms of protected health information.

    (4) Uses and disclosures for disaster relief purposes. A covered entity may use or disclose protected health information to a public or private entity authorized by law or by its charter to assist in disaster relief efforts, for the purpose of coordinating with such entities the uses or disclosures permitted by paragraph (b)(1)(ii) of this section. The requirements in paragraphs (b)(2), (b)(3), or (b)(5) of this section apply to such uses and disclosures to the extent that the covered entity, in the exercise of professional judgment, determines that the requirements do not interfere with the ability to respond to the emergency circumstances.

    (5) Uses and disclosures when the individual is deceased. If the individual is deceased, a covered entity may disclose to a family member, or other persons identified in paragraph (b)(1) of this section who were involved in the individual's care or payment for health care prior to the individual's death, protected health information of the individual that is relevant to such person's involvement, unless doing so is inconsistent with any prior expressed preference of the individual that is known to the covered entity.

     

    HHS Description and Commentary From the January 2013 Amendments
    Uses and Disclosures Requiring an Opportunity for the Individual to Agree or Object: Uses and Disclosures for Involvement in the Individual's Care and Notification Purposes

     

    Proposed Rule

    Section 164.510(b) describes how a covered entity may use or disclose protected health information to persons, such as family members or others, who are involved in an individual’s care or payment related to the individual’s health care. The Department had received a number of questions about the scope of the section, specifically with regard to disclosing protected health information when the individual who is the subject of the information was deceased. We had additionally heard concerns that family members, relatives, and others, many of whom may have had access to the health information of the deceased individual prior to death, have had difficulty obtaining access to such information after the death of the individual, because many do not qualify as a “personal representative” of the decedent under the Privacy Rule at § 164.502(g)(4).

    As such, we proposed to amend § 164.510(b) to add a new paragraph (5), which would permit covered entities to disclose a decedent’s information to family members and others who were involved in the care or payment for care of the decedent prior to death, unless doing so is inconsistent with any prior expressed preference of the individual that is known to the covered entity. We emphasized that these modifications would not change the authority of a decedent’s personal representative with regard to the decedent’s protected health information. Thus, a personal representative would continue to have a right to access the decedent’s protected health information relevant to such personal representation, and have authority to authorize uses and disclosures of the decedent’s protected health information that are not otherwise permitted or required by the Privacy Rule. We requested comment on any unintended consequences that this proposed disclosure provision might cause.

    Overview of Public Comments

    Most commenters supported the proposal to permit disclosures to family members and others involved in the care or payment for care of the decedent prior to death, unless doing so is inconsistent with any prior expressed preference of the individual that is known to the covered entity. These commenters felt that such permissive disclosures would help facilitate important and appropriate communications with family members and others who had been involved in the individual’s care or payment for health care prior to the individual’s death but who may not rise to the level of personal representative. Some commenters stated that the provision recognizes the legitimate interest that family members may have in a decedent’s health information as it affects their own health care.

    A few commenters opposed the proposal to expressly permit communications with family members and other persons who had been involved with the individual’s care or payment for care prior to death. Two commenters felt it would be a large burden on covered entities to determine the legitimacy of a requestor as a family member or individual involved in the care or payment for care. One commenter questioned the need for family members to have access to decedent health information and the likelihood of anyone other than the personal representative to have been meaningfully involved in the care or payment for care of the decedent.

    Final Rule

    The final rule adopts the proposal to amend § 164.510(b) to permit covered entities to disclose a decedent’s protected health information to family members and others who were involved in the care or payment for care of the decedent prior to death, unless doing so is inconsistent with any prior expressed preference of the individual that is known to the covered entity.

    In response to commenters who opposed this provision, we believe the provision strikes the appropriate balance in allowing communications with family members and other persons who were involved in the individual’s care or payment for care prior to death, unless doing so is inconsistent with the prior expressed wishes of the individual.

    This will ensure family members and others can find out about the circumstances surrounding the death of their loved ones, unless the individual prior to his or her death objected to the covered entity making such communications.

    Further, the Privacy Rule limits such disclosures, similar to the other disclosures permitted under § 164.510(b), to the protected health information relevant to the family member or other person’s involvement in the individual’s health care or payment for health care. For example, a covered health care provider could describe the circumstances that led to an individual’s passing with the decedent’s sister who is asking about her sibling’s death. In addition, a covered health care provider could disclose billing information to a family member of a decedent who is assisting with wrapping up the decedent’s estate.

    However, in both of these cases, the provider generally should not share information about past, unrelated medical problems. Finally, these disclosures are permitted and not required, and thus, a covered entity that questions the relationship of the person to the decedent or otherwise believes, based on the circumstances, that disclosure of the decedent’s protected health information would not be appropriate, is not required to make the disclosure.

    Response to Other Public Comments

    Comment: Commenters requested guidance on what it means for a person to have been “involved in the care” of the decedent prior to death. One commenter suggested including language in the final rule that would put the burden of proof of “involvement in the individual’s care” on the requestor and not the covered entity, and would hold the covered entity harmless when disclosing decedent information in good faith in accordance with this new permission.

    Response: We interpret this phrase in the same manner as we have with respect to disclosures of protected health information of living individuals under § 164.510(b). See the Department’s existing guidance at Communicating with a Patient’s Family, Friends, or Others Involved in the Patient’s Care . Subject to the specified conditions, disclosures may be made under this provision to family members, as well as to other persons provided the covered entity has reasonable assurance the individual prior to death was involved in the individual’s care or payment for care. Depending on the circumstances, this could include disclosures to spouses, parents, children, domestic partners, other relatives, or friends of a decedent. As with similar disclosures concerning living individuals under § 164.510(b)(1)(i), this provision does not generally apply to disclosures to health care providers, health plans, public health authorities, law enforcement officials, and others whose access to protected health information is governed by other provisions of the Privacy Rule. We decline to include language in the final rule placing the burden of proof on the requestor to demonstrate they were involved in the individual’s care. In some cases, it will be readily apparent to the covered entity that a person is a family member or was involved in the individual’s care prior to death because the person would have made themselves known to the covered entity prior to the individual’s death by either visiting with or inquiring about the individual, or the individual would have identified such person as being involved in their care or payment for care to a member of the covered entity’s workforce.

    Comment: Several commenters requested and offered suggested clarifications on the scope of the terms “personal representative” and “family member.”

    Further, this final rule includes a definition of “family member” at § 160.103.

    Response: We decline to expand the provision as suggested. Under the Privacy Rule, a person with authority under applicable law to act on behalf of the decedent or the decedent’s estate is the personal representative of the decedent. Thus, certain of these persons, such as the executor of the estate, already have a right of access to the decedent’s protected health information. In cases where a person does not rise to the level of a personal representative, the final rule at § 164.510(b) permits, subject to any prior expressed preference of the individual, a covered entity to disclose relevant protected health information of the decedent to family members of the decedent or persons who otherwise were involved in the individual’s care or payment for care prior to the individual’s death, which may include persons who held a health care proxy for the individual or a medical power of attorney.

     

    Under the final rule, we specify that covered entities may disclose to a person involved in the current health care of the individual (such as a family member, other relative, close personal friend, or any other person identified by the individual) protected health information directly related to the person's involvement in the current health care of an individual or payment related to the individual's health care. Such persons involved in care and other contact persons might include, for example: blood relatives; spouses; roommates; boyfriends and girlfriends; domestic partners; neighbors; and colleagues. Inclusion of this list is intended to be illustrative only, and it is not intended to change current practices with respect to: (1) involvement of other persons in individuals' treatment decisions; (2) informal information-sharing among individuals involved in a person's care; or (3) sharing of protected health information to contact persons during a disaster. The final rule also includes new language stating that covered entities may use or disclose protected health information to notify or assist in notification of family members, personal representatives, or other persons responsible for an individual's care with respect to an individual's location, condition, or death. These provisions allow, for example, covered entities to notify a patient's adult child that his father has suffered a stroke and to tell the person that the father is in the hospital's intensive care unit.

    We proposed that when a covered entity could not practicably obtain oral agreement to disclose protected health information to next-of-kin, relatives, or those with a close personal relationship to the individual, the covered entity could make such disclosures consistent with good health professional practice and ethics. In such instances, we proposed that covered entities could disclose only the minimum information necessary for the friend or relative to provide the assistance he or she was providing. For example, health care providers could not disclose to a friend or relative simply driving a patient home from the hospital extensive information about the patient's surgery or past medical history when the friend or relative had no need for this information.

    This provision is intended to allow disclosures directly related to a patient's current condition and should not be construed to allow, for example, disclosure of extensive information about the patient's medical history that is not relevant to the patient's current condition and that could prove embarrassing to the patient. In addition, if a covered entity suspects that an incapacitated patient is a victim of domestic violence and that a person seeking information about the patient may have abused the patient, covered entities should not disclose information to the suspected abuser if there is reason to believe that such a disclosure could cause the patient serious harm. In all of these situations regarding possible disclosures of protected health information about an patient who is not present or is unable to agree to such disclosures due to incapacity or other emergency circumstance, disclosures should be in accordance with the exercise of professional judgment as to the patient's best interest.

    Like the NPRM, the final rule does not require covered entities to verify the identity of relatives or other individuals involved in the individual's care. Rather, the individual's act of involving the other persons in his or her care suffices as verification of their identity. For example, the fact that a person brings a family member into the doctor's office when treatment information will be discussed constitutes verification of the involved person's identity for purposes of this rule. Likewise, the fact that a friend arrives at a pharmacy and asks to pick up a specific prescription for an individual effectively verifies that the friend is involved in the individual's care, and the rule allows the pharmacist to give the filled prescription to the friend.

    The NPRM did not specifically address situations in which disaster relief organizations may seek to obtain protected health information from covered entities to help coordinate the individual's care, or to notify family or friends of an individual's location or general condition in a disaster situation. In the final rule, we account for disaster situations in this paragraph. Specifically, we allow covered entities to use or disclose protected health information without individual agreement to federal, state, or local government agencies engaged in disaster relief activities, as well as to private disaster relief or disaster assistance organizations (such as the Red Cross) authorized by law or by their charters to assist in disaster relief efforts, to allow these organizations to carry out their responsibilities in a specific disaster situation. Covered entities may make these disclosures to disaster relief organizations, for example, so that these organizations can help family members, friends, or others involved in the individual's care to locate individuals affected by a disaster and to inform them of the individual's general health condition. This provision also allows disclosure of information to disaster relief or disaster assistance organizations so that these organizations can help individuals obtain needed medical care for injuries or other health conditions caused by a disaster.

     

    HHS Response to Comments Received From the Original Rulemaking
    Uses Uses and Disclosures Requiring an Opportunity for the Individual to Agree or Object: Uses and Disclosures for Involvement in the Individual's Care and Notification Purposes

    Comment: A number of comments supported the NPRM's proposed approach, which would have allowed covered entities to disclose protected health information to the individual's next of kin, family members, or other close personal friends when the individual verbally agreed to the disclosure. These commenters agreed that the presumption should favor disclosures to the next of kin, and they believed that health care providers should encourage individuals to share genetic information and information about transmittable diseases with family members at risk. Others agreed with the general approach but suggested the individual's agreement be noted in the medical record. These commenters also supported the NPRM's proposed reliance on good professional practices and ethics to determine when disclosures should be made to the next of kin when the individual's agreement could not practicably be obtained.

    One commenter favored disclosures to family members and others unless the individual actively objected, as long as the disclosure was consistent with sound professional practice. Others believed that no agreement by the individual was necessary unless sensitive medical information would be disclosed or unless the health care provider was aware of the individual's prior objection. These commenters recommended that good professional practice and ethics determine when disclosures were appropriate and that disclosure should relate only to the individual's current treatment. A health care provider organization said that the ethical and legal obligations of the medical professional alone should control in this area, although it believed the proposed rule was generally consistent with these obligations.

    We do not agree with the comments stating that all such disclosures should be made only with consent or with the individual's written authorization. The rule does not prohibit obtaining the agreement of the individual in writing; however, we believe that imposing a requirement for consent or written authorization in all cases for disclosures to individuals involved in a person's care would be unduly burdensome for all parties. In the final rule, we clarify the circumstances in which such disclosures are permissible. The rule allows covered entities to disclose to family members, other relatives, close personal friends of the individual, or any other person identified by the individual, the protected health information directly relevant to such person's involvement with the individual's care or payment related to the individual's health care. In addition, the final rule allows covered entities to use or disclose protected health information to notify, or assist in the notification of (including identifying or locating) a family member, a personal representative of the individual, or another person responsible for the care of the individual, of the individual's location, general condition, or death. The final rule includes separate provisions for situations in which the individual is present and for when the individual is not present at the time of disclosure. When the individual is present and can make his or her own decisions, a covered entity may disclose protected health information only if the covered entity: (1) obtains the individual's agreement to disclose to the third parties involved in the individual's care; (2) provides the individual with the opportunity to object to the disclosure, and the individual does not express an objection; or (3) reasonably infers from the circumstances, based on the exercise of professional judgment, that the individual does not object to the disclosure. The final rule continues to permit disclosures in circumstances when the individual is not present or when the opportunity to agree or object to the use or disclosure cannot practicably be provided due to the individual's incapacity or an emergency circumstance. In such instances, covered entities may, in the exercise of professional judgment, determine whether the disclosure is in the individual's best interests and if so, disclose only the protected health information that is directly relevant to the person's involvement with the individual's health care.

    Comments: A few comments supported the NPRM approach because it permitted the current practice of allowing someone other than the patient to pick up prescriptions at pharmacies. One commenter noted that this practice occurs with respect to 25-40% of the prescriptions dispensed by community retail pharmacies. These commenters strongly supported the proposal's reliance on the professional judgment of pharmacists in allowing others to pick up prescriptions for bedridden or otherwise incapacitated patients, noting that in most cases it would be impracticable to verify that the person was acting with the individual's permission. Two commenters requested that the rule specifically allow this practice. One comment opposed the practice of giving prescriptions to another person without the individual's authorization, because a prescription implicitly could disclose medical information about the individual.

    Comment: We received a few comments that misunderstood the provision as addressing disclosures related to deceased individuals.

    Comments: A number of commenters expressed concern for the interaction of the proposed section with state laws. Some of these comments interpreted the NPRM's use of the term next of kin as referring to individuals with health care power of attorney and thus they believed that the proposed rule's approach to next of kin was inappropriately informal and in conflict with state law. Others noted that some state laws did not allow health care information to be disclosed to family or friends without consent or other authorization. One commenter said that case law may be evolving toward imposing a more affirmative duty on health care practitioners to inform next of kin in a variety of circumstances. One commenter noted that state laws may not define clearly who is considered to be the next of kin.

    The comments suggesting that state laws may not allow the disclosures otherwise permitted by this provision or, conversely, that they may impose a more affirmative duty, did not provide any specifics with which to judge the affect of such laws. In general, however, state laws that are more protective of an individual's privacy interests than the rule by prohibiting a disclosure of protected health information continue to apply. The rule's provisions regarding disclosure of protected health information to family or friends of the individual are permissive only, enabling covered entities to abide by more stringent state laws without violating our rules. Furthermore, if the state law creates an affirmative and binding legal obligation on the covered entity to make disclosures to family or other persons under specific circumstances, the final rule allows covered entities to comply with these legal obligations. See § 164.512(a).

    Other comments expressed concern for disclosures related to particular types of information. For example, two commenters recommended that psychotherapy notes not be disclosed without patient authorization. One commenter suggested that certain sensitive medical information associated with social stigma not be disclosed to family members or others without patient consent.

    We agree with the recommendation to require written authorization for a disclosure of psychotherapy notes to family, close personal friends, or others involved in the individual's care. As discussed below, the final rule allows disclosure of psychotherapy notes without authorization in a few limited circumstances; disclosure to individuals involved in a person's care is not among those circumstances. See § 164.508 for a further discussion of the final rule's provisions regarding disclosure of psychotherapy notes.

    Comment: One commenter suggested that this provision should allow disclosure of protected health information to the clergy and to the Red Cross. The commenter noted that clergy have ethical obligations to ensure confidentiality and that the Red Cross often notifies the next of kin regarding an individual's condition in certain circumstances. Another commenter recommended allowing disclosures to law enforcement for the purpose of contacting the next of kin of individuals who have been injured or killed. One commenter sought clarification that “close personal friend” was intended to include domestic partners and same-sex couples in committed relationships.

    As discussed in the preamble of the final rule, this provision allows disclosures to domestic partners and others in same-sex relationships when such individuals are involved in an individual's care or are the point of contact for notification in a disaster. We do not intend to change current practices with respect to involvement of others in an individual's treatment decisions; informal information-sharing among persons involved; or the sharing of protected health information during a disaster. As noted above, a power of attorney or other legal relationship to an individual is not necessary for these informal discussions about the individual for the purpose of assisting in or providing a service related to the individual's care.

    Comment: One commenter recommended stating that individuals who are mentally retarded and unable to agree to disclosures under this provision do not, thereby, lose their access to further medical treatment. This commenter also proposed stating that mentally retarded individuals who are able to provide agreement have the right to control the disclosure of their protected health information. The commenter expressed concern that the parent, relative, or other person acting in loco parentis may not have the individual's best interest in mind in seeking or authorizing for the individual the disclosure of protected health information.

    In the final rule, § 164.510(b) may apply to permit disclosures to a person other than a personal representative. Under § 164.510(b), when an individual is present and has the capacity to make his or her own decisions, a covered entity may disclose protected health information only if the covered entity: (1) obtains the individual's agreement to disclose protected health information to the third parties involved in the individual's care; (2) provides the individual with an opportunity to object to such disclosure, and the individual does not express an objection; or (3) reasonably infers from the circumstances, based on the exercise of professional judgment, that the individual does not object to the disclosure. These conditions apply to disclosure of protected health information about individuals with mental retardation as well as to disclosures about all other individuals. Thus we do not believe it is necessary to include in this section of the final rule any language specifically on persons with mental retardation.

    Response: We generally agree with commenters regarding disclosure in good faith pursuant to this provision. As discussed above, the final rule expands the scope of individuals to whom covered entities may disclose protected health information pursuant to this section. In addition, we delete the term next of kin, to avoid the appearance of requiring any legal determination of a person's relationship in situations involving informal disclosures. Similarly, consistent with the informal nature of disclosures pursuant to this section, we do not require covered entities to document such disclosures. If a covered entity imposes its own documentation requirements and a particular covered health care provider does not follow the entity's documentation requirements, the disclosure is not a violation of this rule.

    Response: We agree with the comments that victims of domestic violence and other forms of abuse need special consideration in order to avoid further harm, and we provide for discretion of a covered entity to determine that protected health information not be disclosed pursuant to § 164.510(b). Section 164.510(b) of the final rule, disclosures to family or friends involved in the individual's care, states that when an individual is unable to agree or object to the disclosure due to incapacity or another emergency situation, a covered entity must determine based on the exercise of professional judgment whether it is in the individual's best interest to disclose the information. As stated in the preamble, we intend for this exercise of professional judgment in the individual's best interest to account for the potential for harm to the individual in cases involving domestic violence. These circumstances are unique and are best decided by a covered entity, in the exercise of professional judgment, in each situation rather than by a blanket rule.