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Information Resources and Technology


Health Insurance Portability and Accountability Act of 1996 (HIPAA)

This is a policy article providing information on the Health Insurance Portability and Accountability Act of 1996 (HIPAA), which Sacramento State staff members are required to learn.
  1. Introduction
  2. The HIPAA Privacy Rule
    1. Important Definitions
      1. HIPAA (Health Insurance Portability and Accountability Act) Definitions
  3. Disclosure of PHI Outside Sacramento State
  4. Safeguarding PHI
    1. Use Only The Minimum Necessary Information
    2. Discussing PHI With a Patient's Family Members
    3. Patient's Rights Under the Privacy Rule


As a staff member at Sacramento State, you are required to learn about the health information privacy requirements of a federal law called HIPAA (Health Insurance Portability and Accountability Act). The health information privacy requirements are known as the HIPAA Privacy Rule and go into effect beginning April 14, 2003. When you are at a Sacramento State, you must follow that campus policies and procedures, including those concerning health information privacy.

Thank you for taking time to learn about the HIPAA Privacy Rule

The HIPAA Privacy Rule

The Privacy Rule defines how health care providers, staff, trainees and students in clinical training programs can use, disclose, and maintain identifiable patient information, called "Protected Health Information" ("PHI"). PHI includes written, spoken, and electronic information and images.

PHI is health information or health care payment information that identifies or can be used to identify an individual patient. The Privacy Rule very broadly defines identifiers to include not only patient name, address, and social security number, but also, for example, fax numbers, email addresses, vehicle identifiers, URLs, photographs, and voices or images on tape or electronic media. When in doubt, you should assume that any individual health information is protected under the Privacy Rule.

All patients you come into contact with at your training site will have received a Notice of Privacy Practices, which describes in detail permitted uses and disclosures of PHI and patient rights (discussed below) under the Privacy Rule.

Important Definitions

  • USE: the sharing, application, utilization, examination, or analysis of PHI by employees and trainees within the training site.
  • DISCLOSURE: discussing PHI with or providing copies of PHI to persons who are not employees or trainees of the training site.

HIPAA (Health Insurance Portability and Accountability Act) Definitions

  1. HIPAA (Health Insurance Portability and Accountability Act):A set of standards for the security of electronic protected health information that by health plans, health care clearinghouses, and certain health care providers must implement.
  2. PHI (Protected Health Information):Any information (such as a name,address, photo, etc.) that identifies real people in a health care setting.
  3. Access Control: The act of limiting a user's access to certain data or files based on role or job function.
  4. Account Creation: This is the process of creating an account (or some other access point) on a computer system and granting it permission to access or use some subset of files or data. Security policies developed by the organization should govern this process. The policies should not only address the creation of the account, but should also address how long the account exists and describe the conditions in which the organization terminates the accoun.
  5. Data Browsing: The act of viewing data or records not directly within the scope of one's job functions at the time. For example, a health care provider looking at records of patients not under that provider's care. Access Level: The "rights" a user account has concerning access to a file or data. These will vary among operating systems, but usually include: read (the ability to look at a file or its contents), write (the ability to create a file or modify an existing file's contents), and delete (the ability to erase a file).

Disclosure of PHI Outside Sacramento State

You may use PHI, without patient authorization, at the training site for purposes of treatment and your training at that site. However, you may not further disclose PHI in any form to anyone outside of the training site, without first obtaining written patient authorization or de-identifying the PHI. This means that you may not, for example, discuss or present PHI from a training facility with or to anyone, including classmates or faculty, who was not directly involved in your training at that facility, unless you first obtain written authorization from the patient. Therefore, you must de-identify PHI, as described below, before presenting any patient information outside of the training facility. If you are unable to de-identify such information, you must discuss your need for identifiable information with the faculty member supervising your training and the HIPAA Privacy Coordinator at your training site, to determine the appropriate procedures for obtaining patient authorization for your disclosure of PHI.

In order for PHI to be considered de-identified under the Privacy Rule, all of the following identifiers of the patient or of relatives, employers, or household members of the patient, must be removed:

  1. Name
  2. Geographic subdivisions smaller than a state (i.e., county, town, or city, street address, and zip code) (note: in some cases, the initial three digits of a zip code may be used)
  3. All elements of dates (except year) for dates directly related to an individual (including birth date, admission date, discharge date, date of death, all ages over 89 and dates indicative of age over 89) (note: ages and elements may be aggregated into a single category of age 90 or older)
  4. Phone numbers
  5. Fax numbers
  6. Email addresses
  7. Social security number
  8. Medical record number
  9. Health plan beneficiary number
  10. Account number
  11. Certificate/license number
  12. Vehicle identifiers and serial numbers
  13. Device identifiers and serial numbers
  14. URLs
  15. Internet protocol addresses
  16. Biometric identifiers (i.e., fingerprints)
  17. Full face photographic or any comparable images
  18. Any other unique identifying number, characteristic, or code
  19. Any other information that could be used alone or in combination with other information to identify the individual

Safeguarding PHI

The Privacy Rule requires you to "safeguard" PHI at your training site. Use the following practices to ensure Privacy Rule compliance.

  • If you see a medical record in public view where patients or others can see it, cover the file, turn it over, or find another way to protect it.
  • When you talk about patients as part of your training, try to prevent others from overhearing the conversation. Whenever possible, hold conversations about patients in private areas. Do not discuss patients while you are in elevators or other public areas.
  • When medical records are not in use, store them in offices, shelves or filing cabinets.
  • Remove patient documents from faxes and copiers as soon as you can.
  • When you throw away documents containing PHI, follow the facility procedures for disposal of documents with PHI.
  • Never remove the patient's official medical record from the training site.
  • Avoid removing copies of PHI from the training site; if you must remove copies of PHI from the training site, e.g., to complete homework, take appropriate steps to safeguard the PHI outside of the training site and properly dispose of the PHI when you are done with it. You should not leave PHI out where your family members or others may see it. All copies of PHI should be shredded when they are no longer needed for your training purposes.

Use Only The Minimum Necessary Information

When you use PHI, you must follow the Privacy Rule's minimum necessary requirement by asking yourself the following question: "Am I using or accessing more PHI than I need to?" If you are unsure of the PHI you may access or use while providing care for a patient at your training site, please contact your preceptor, supervisor, or the HIPAA Privacy Coordinator at your training site.

Discussing PHI With a Patient's Family Members

Before you may discuss a patient's condition, treatment or other PHI with his or her family member, it must be determined if the patient would object to such a disclosure. You should confirm with your supervisor that the patient has agreed to allow or in some other way has expressed no objection to such disclosures before you may discuss a patient's condition, treatment, or other PHI with his/her family members.

Patient's Rights Under the Privacy Rule

Each training site covered by the HIPAA Privacy Rule will have policies and procedures for implementing the following patient rights under the Privacy Rule:

  • The right to request alternative communications. Under the Privacy Rule, patients can ask to be contacted in a certain way. For example, a patient may ask a nurse if she/he can leave a message on the patient's home voicemail instead of contacting the patient at work. If a patient's request is reasonable, as is the previous example, the health care provider or facility must follow it.
  • The right to look at (and obtain copies of) records. Patients can ask to read their medical and billing records, and have copies made.
  • The right to ask for changes to medical and billing records. Each facility must review and consider all requests for changes to medical and billing records.
  • The right to receive a list of certain disclosures. Your training site must make and keep a list of certain disclosures of PHI (excluding disclosures for treatment, payment, and health care operations) that are made without patient authorization. Patients have the right to see and receive a copy of this list.
  • The right to request restrictions on how PHI is used and disclosed. Patients can ask health care providers and facilities to limit the ways they make use of and disclose the patient's PHI for treatment, payment, and health care operations. Providers and facilities are not required to agree to such requests. You, as a trainee, must never agree to such restrictions on behalf of the training site.
  • The right to receive a "Notice of Privacy Practices". Each health care facility that provides direct patient care must give every patient/client a copy of their Notice of Privacy Practices. The notice describes their privacy practices and the Privacy Rule. The facility must make reasonable efforts to have each patient sign a form acknowledging he or she received the notice. We recommend that you obtain a copy of the Notice of Privacy Practices from your training site and become familiar with it.

Information Security - KB0011403 by Long Lim | Published:2016-02-26 | Updated:2017-10-13 10:47:13 | Views::145

Version 1.4.2 (release notes)