Individual Assignment 4

Section 164.510(b) of the Privacy Rule describes three ways that a provider can determine

whether the patient agrees or objects to a disclosure, including:

1. Obtaining the individual’s agreement to the disclosure

2. Providing the individual with a specific opportunity to object to the disclosure, and the

individual does not express an objection to the disclosure

3. Reasonably inferring from the circumstances, based on the exercise of professional

judgment, that the individual does not object to the disclosure

Part 1: Assume you are a hospital compliance officer and have been tasked with creating

privacy and security policies and procedures for your organization.

 In crafting your policies and

procedures, how would you structure your institution’s approach and why? Many disclosures of

PHI are permitted based on the relationship of the person seeking information to the patient.

What techniques should your hospital adopt through its policies for verifying the identity of an

individual to whom information about the patient could be disclosed or to verify the individual’s

relationship to the patient? 

Would you adopt a single approach, or would your policy vary, for

instance, based on the circumstances? Please write up a brief response (2–3 pages max, double

spaced) addressing these questions. Note that you do not have to create actual policies and

procedures in crafting your response to these questions.

Part 2: How would your policy apply in each of the cases below (e.g., are there certain people or

categories of individuals with whom information regarding the condition and treatment of the

patient would always, sometimes, or never be shared)? Please give support for your conclusions.

A. A school bus has overturned, and 30 elementary school children are rushed to your

hospital. Some are in serious condition, some are dead when they arrive at the

hospital, and some have merely cuts and bruises and will be released shortly. As the

person the hospital has designated the contact person regarding patients involved in

this terrible accident, from whom would you likely receive requests for information

about these children and their condition? To whom would you disclose PHI and to

whom would you not disclose PHI? Why?

B. An elderly widow who lives alone is brought to the ER by a neighbor who found the

woman partially conscious in the hallway of her apartment building. The neighbor tells

the ER intake clerk that the patient lives alone but has a daughter who lives 200 miles

away and a grandson who lives in the same town but has not seen his grandmother in

10 years. Who could the hospital notify? Is there anyone else to whom information

about the patient’s condition could be disclosed? What, if anything, could the hospital

tell the neighbor who brought the woman in about the patient’s condition?

C. A 12-year-old girl is brought to the ER by a schoolmate and the schoolmate’s mother. The

girl claims that she has been attacked and raped. Her parents are divorced, and her mother,

who is at work, has sole custody of the child, although her father lives nearby in the same

town. Who could the hospital notify? To whom could information about the patient be

disclosed, if asked? What, if anything, could the hospital tell the people who brought the

girl to the ER about the patient’s condition?

D. A famous singer falls off her horse in a nasty riding accident and is rushed to the

hospital. She signs in under an assumed name. What PHI could be disclosed about the

singer and her medical condition, and to whom could it be disclosed?