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Administrative (Non-Clinical) Policy
This administrative policy applies to the operations and staff of the University of Wisconsin Hospitals and
Clinics Authority (UWHCA) as integrated effective July 1, 2015, including the legacy operations and
staff of University of Wisconsin Hospital and Clinics (UWHC) and University of Wisconsin Medical
Policy Title: Release of Alcohol and Other Drug Abuse Patient Information
Policy Number: 4.38
Effective Date: October 1, 2016
Chapter: Legal Services
In order to protect the interest of patients who are, or have been, primarily treated for alcohol and other
drug abuse (AODA), and to comply with Federal and state laws, regulations or codes, it is the policy of
this institution that the protected health information ("PHI") pertaining to the patient, spoken or written,
regarding the patient's care or treatment by UW Health, shall remain confidential, and may be released
only as provided by this policy.
II. POLICY ELEMENTS
In accordance with Federal regulations and State Statutes and Codes PHI pertaining to patients currently
or previously participating in an AODA treatment programs shall remain confidential within UW Health
and except as provided in Section V.C. may only be released with written authorization of the following
A. If the patient is 12 years or older, is not judged incompetent, and has obtained outpatient or
detoxification treatment for alcohol and drug addiction, consent to release information must
be obtained from the patient directly.
B. If the patient is between 12 and 18 and has obtained inpatient treatment for alcohol and drug
addiction, or is judged incompetent, consent to release the treatment records must be obtained
from the patient and the parent, guardian, or person in place of the guardian.
Medical records for AODA patients must be securely maintained when not in use. A policy
governing the control and access to these records shall be implemented by the Health
Information Management Department to insure their confidentiality.
42 Code of Federal Regulations, Part 2; Wisconsin Statutes sec. 51.30
Authorization for the Release of Medical Information form, UWH form #1280490-DT
Authorization for Exchange of Written and Verbal Communication, UWH form #1280490EXCH-DT
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Authorization for Verbal Communication and to Leave Voice Mail Messages, UWH form #1280490V-
A. Written Authorization for Release of AODA Patient Information
1. State and Federal law require certain elements to be present in a written authorization
to be valid. Therefore, whenever possible, the UW Health "Authorization for Release
of Medical Information" form should be used. When UW Health's form is not used for
written authorization, Health Information Management should be contacted to review
the authorization for its validity.
B. General Information, Release of PHI Pertaining to AODA Patients.
1. Unless the patient requests to be listed as "confidential," UW Health may confirm that a
patient is, or has been, admitted to the hospital in general, without specification of unit,
diagnosis or date of treatment. Other specific information can only be released with a
written authorization or with an appropriate court order.
2. Information requests from treatment programs, patient's private physician or other
providers outside UW Health may only be released with written authorization using
UW Health's "Authorization for Release of Medical Information" form or other HIPAA
compliant form that specifically identifies that AODA records may be released. If more
than one treatment program is to receive information, the various programs shall be
listed on separate authorizations. Accounting for the disclosure is documented on the
informed consent (or using Quick Disclosure, if authorization is not required). The
completed authorization must be filed in the patient record.
C. Release of PHI without Written Authorization
1. PHI may be released without written authorization by the Health Information
Management Department only under the following circumstances as delineated in 42
CFR part 2(D):
a. When immediate medical intervention is required to alleviate an immediate
threat to the health of any person, information may be disclosed to medical
i. The program may be required to provide immediate release of
information in emergency situations.
ξ Following the release of information for an emergency,
the program shall document the release using Quick
b. When the Food and Drug Administration (FDA) has reason to believe that
the health of any individual may be threatened due to an error in the
manufacture, labeling, or sale of a product under FDA jurisdiction,
information may be disclosed to FDA medical personnel for the sole purpose
of notifying patient or their physicians of the potential danger. Following the
release of information to the FDA, Health Information Management shall
document the release and include:
i. The name of the medical personnel to whom the information was
released and their affiliation with any health care facility.
ii. The name of the individual making the disclosure.
iii. The date and time of the release.
iv. The nature of the emergency (or error, if the report was to the
c. When information is needed by personnel in UW Health, in connection with
their duties that arise from the patient's diagnosis, treatment or referral for
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treatment of AODA, patient information may be accessed by UW Health
personnel with such a need to know.
d. When conducting approved scientific research, information can be released if
the researcher is: qualified to conduct the research; the protocol includes a
process for maintaining confidentiality, and restricts re-disclosure; the
protocol has been approved by the Center for Health Sciences Human
e. When an audit or evaluation is being conducted
i. PHI may be reviewed on the premises if the reviewer agrees, in
writing, not to re-disclose the information.
ii. PHI may be copied and removed from the premises if the
reviewer agrees, in writing, not to re-disclose information,
insures confidentiality of information and destroys all patient
identifying information following completion of the audit or
a. Governmental agency, third party payer, or quality
improvement organization performing a utilization or
b. Medicare and Medicaid auditors or evaluators may
receive information for the sole purpose of their audit or
evaluation and may not re-disclose the information.
c. Access to PHI by outside auditors must be documented
using UW Health’s Health Link Quick Disclosure.
d. Patient information disclosed under this section may be
disclosed only back to UW Health to carry out an audit
or evaluation or to investigate or prosecute criminal or
other activity as authorized by a court order.
f. PHI includes patient’s name, address, social security number, fingerprints,
photograph, medical record number, or similar information by which the
identity of a patient can be determined with reasonable accuracy and speed
either directly or by reference to other publicly available information.
2. Other than the exceptions listed above in V.C.1., release may be made only by a court
order, complying with 42 CRF SS 2.61-2.67, which contain unique provisions as to
how the order can be obtained.
D. Patient Right to Access their Medical Record
1. Patients have the right to access and review their own medical record. Patients may
access their medical record during treatment in accordance with Hospital Patient Care
Policy 4.14-Release of Mental Health Information and Hospital Administrative Policy
6.13-Patient Right to Access Their medical Record and UWMF Policy 107.011-Patient
Right to Access, Inspect and Copy PHI.
2. Patients who are under the age of 12 years may review their record but only in the
presence of the legal guardian. Patients 12 years of age or older have the right to review
their own records without the presence of their legal guardian.
3. Following discharge, patients have a right to obtain a copy of their medical record in
accordance with sec. 51.30(4) (d) (2-4) Wis. Stat.
4. Use of information obtained from the record is restricted from being used to initiate or
substantiate any criminal charges against a patient, or to conduct any criminal
investigation of a patient, unless such criminal investigation is being done under a court
E. Maintenance of AODA Medical Records
1. Health Information Management personnel shall follow state and federal requirements
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when releasing medical records including documentation within the medical record of
each release of the record pursuant to Hospital Administrative Policy 4.13-Using and
Disclosing (or Releasing) Protected health Information; Hospital Administrative Policy
4.14-Release of Mental Health Information and UWMF Policy 107.018-Release and
Disclosure of Protected Health Information.
a. The following statement should be included with each release of an AODA
This information has been disclosed to you from records protected by
Federal confidentiality rules (42 CFR part 2). The Federal rules prohibit
you from making any further disclosure of this information unless further
disclosure is expressly permitted by the written consent of the person to
whom it pertains or as otherwise permitted by 42 CFR part 2. A general
authorization for the release of medical or other information is NOT
sufficient for this purpose. The Federal rules restrict any use of the
information to criminally investigate or prosecute any alcohol or drug
F. AODA service documentation is maintained in the UW Health EHR and access is restricted to
those with appropriate security. UW Health employees supervising students in training programs
are responsible for informing them of the obligations stated in this policy.
G. All media inquiries concerning a specific patient, patient care procedures or programs must be
directed to the Marketing and Communications Department.
Sr. Management Sponsor: SVP, Chief Information Officer
Author: Director, Health Information Management
Reviewer(s): Manager, Adolescent Alcohol/Drug Assessment Intervention Program; UW Health Privacy
Approval committee: UW Health Administrative Policy and Procedure Committee
UW Health Chief Administrative Officer
Previous Revision: 062013
Next Revision: 102019