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Administrative (Non-Clinical) Policy
UWHC only (Hospital Administrative-entity wide) UWMF only (entity wide)
UWHC Departmental (indicate name) UWMF Departmental (indicate name)
UWHC and UWMF (shared)
Policy Title: Accounting of Protected Health Information Disclosures
Policy Number: 6.23
Effective Date: March 1, 2015
Chapter: Medical Records
To define and to establish a process for those disclosures that UWHC staff are required to track for patient
State and federal law provide patients or their legally authorized representative with a right to receive an
"accounting" of certain types of disclosures upon request. The types of disclosures a patient or their
legally authorized representative has a right to an accounting of is listed in (IV)(A).
Upon request, UWHC will provide to a patient or the patient's legally authorized representative, an
"accounting" of those disclosures of the patient's protected health information ("PHI") that we are
required to track under state and federal law.
A. Protected Health Information ("PHI") - individually identifiable health information that is
transmitted or maintained in any form, including oral, written, or electronic. PHI includes
demographic, health, and financial information.
B. Disclosure - the releasing, transferring, providing access or divulging information to any person
or organization outside of "UWHC Related Entities."
C. Legally Authorized Representative - a person with authority to act on behalf of an adult,
emancipated minor, unemancipated minor, or deceased individual in making decisions related to
health care. The legally authorized representative of unemancipated minors includes a parent,
guardian, or other persons acting in place of the parents of the minor.
D. Treatment - the provision, coordination, or management of health care and related services.
E. Payment - the activities undertaken by health plan or health care provider to obtain or provide
reimbursement for the provision of care.
F. Health Care Operations - activities undertaken by UWHC as part of business operations. They
1. Quality assessment/quality improvement
2. Reviewing the competence or qualifications of a health care provider
3. Conducting or arranging for medical review, legal services, auditing etc
4. Business planning and development
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5. Business management and administrative activities such as customer service activities
and resolution of internal grievances
G. UWHC Related Entities - includes persons and organizations affiliated with UWHC and those in
an organized health care arrangement with UWHC.
A. The following lists disclosures, whether made orally, electronically, manually, or faxed, that must
be tracked under state and federal law for purposes of providing an accounting to patients or their
legally authorized representative:
1. Disclosures made to report the following under state law:
a. Caregiver misconduct
b. Death due to restraints or psychotropic drugs
c. Wounds or burns suspected of being linked to a crime
d. Suspected child abuse
e. Coroner cases
f. Sexual exploitation by a therapist
i. Birth defects
k. Communicable diseases including STD's and HIV results
l. Lead poisoning or exposure
m. Persons with cancerous or precancerous conditions
n. Elder abuse
o. Impaired drivers
2. Disclosures to employers for surveillance purposes or to conduct medical surveillance to
evaluate a work related injury.
3. Disclosures to state advocacy and protection agencies for people with mental illness
and/or developmental disabilities.
4. Reports to school districts (unless made pursuant to an authorization).
5. To the Department of Corrections regarding prisoner.
6. Disclosures to court appointed examiners to assess accused's mental health status.
7. Disclosures to law enforcement personnel for the following purposes:
a. Pursuant to a court order, warrant, or similar legal process
b. To locate a fugitive or suspect of a crime
c. To gain information about a victim of a crime
d. To provide information about a patient who has died if it is suspected that
the patient died as a result of a crime
e. To report a crime, including those that occur on UWHC premises
f. To avert a serious threat to health or safety
8. Disclosures to an agency for health care oversight (e.g. Bureau of Quality Assurance,
Medicare audits, criminal investigations etc.)
9. Disclosures made pursuant to court orders and other judicial proceedings.
10. Disclosures made for specialized military functions.
11. Disclosures made to U.S. Department of Health and Human Services (DHHS) to review
UWHC's compliance with HIPAA.
B. Those disclosures for which a patient or their legally authorized representative have a right to an
accounting shall be documented, tracked, or logged in order to respond to requests. The following
documentation elements must be listed or linked to each of these disclosures (even if it is a state
required disclosure and the statute requires the use of a specific form to make the report):
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1. The date of the disclosure.
2. The name and if known, addresses of the person or organization that received the
3. A description of the information disclosed.
4. A statement of the purpose of the disclosure.
C. To effectively process a request for an accounting of disclosures, those disclosures that must be
tracked for accounting purposes must be documented, tracked, or logged utilizing one of the
following internal processes:
1. UWHC's "Accounting of Disclosures Documentation" form. This form must be
completed and sent to HIM to be filed in the medical record.
2. A computerized process that can link or contains the information listed in IV (B) for
3. Maintain copies of written requests for PHI. Requests are filed in the medical record.
4. Lists created in response to request for access to PHI for investigation purposes (HIM,
ITS, and other departments affected by this policy will keep track of these lists).
5. Copies of forms required by the state when making required reporting.
D. All requests for an accounting of disclosures are to be directed to the Department of Health
Information Management ("HIM") for processing.
1. UWHC has sixty (60) days to act on a request for an accounting of disclosures. One thirty
(30) day extension is allowed provided the individual making the request is informed in
writing of the delay, the reason for the delay, and the date the accounting will be
2. Individuals requesting an accounting of disclosures will be required to complete UWHC's
"Request for an Accounting of Disclosures" form. HIM will process the request for an
accounting of disclosures, and will provide the patient with a copy of the "Report of
Disclosures of Protected Health Information" form.
3. A copy of the "Report of Disclosures of Protected Health Information" form will be filed
in the Outside Documents section of the patient record.
4. UWHC will provide an accounting of disclosures to the patient at no charge for a request
made once during any twelve-month period. The individual making the request will be
notified in advance that additional requests in a twelve-month period will be assessed a
reasonable, cost-based fee.
5. Written requests for an accounting and written accountings provided to a patient will be
maintained for at least six years from the date it was created.
Request for an Accounting of Disclosures
Report of Disclosures of Protected Health Information
Sr. Management Sponsor: CIO
Author: Compliance and Privacy Officer
Approval Committee: Administrative Policy & Procedure Committee
President & CEO
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Previous revision: March 2012
Next revision: March 2018