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?