Accounting of Disclosure Policy & Guidelines (107.002)

Accounting of Disclosure Policy & Guidelines (107.002) - Policies, Administrative, UWMF, UWMF-wide, HIPAA/Privacy


** Supplement to Accounting requirements specified in UWMF “Release & Disclosure of PHI”
Policy / Privacy 001, effective April 14, 2003.
University of Wisconsin Medical Foundation

Policy Name: Accounting of Disclosure Policy &
Policy Number: Privacy #019

__X__ New* ____ Revised

If Revised, Supersedes Policy Dated: _________

Effective Date: April 14, 2003*
Approved By (Name): Peter Christman

Title: Executive Vice President

I. Purpose

The purpose of this policy is to comply with State and Federal laws and to ensure that, upon
request, a patient receives an accounting of disclosures of his/her Protected Health Information
(“PHI”) record. A patient may request an accounting of disclosures of her/his PHI for those
disclosures that were made up to six years prior to the date of the patient’s request.

II. Policy

The University of Wisconsin Medical Foundation (“UWMF”) maintains an accounting of
disclosure forms in each patient’s record of the PHI disclosed, as below, for at least six years.
These forms shall include disclosures made to or by UWMF business associates.

III. Procedure

A. PHI Disclosure Accounting
For each disclosure, the accounting form is filled out and includes, at a minimum:

1. Date of disclosure.

2. Name of individual (person) or entity who received the information and, if known,
the address of person or entity.

3. Brief description of the protected health information disclosed.

4. Brief statement of the purpose of the disclosure that reasonably informs the person of
the basis for the disclosure or a copy of the written request for disclosure, if the
disclosure was required by law or did not require the patient/client’s authorization.

5. At least a summary entry for multiple disclosures made to the same party for a single
purpose. A summary entry for a specific accounting period will include:

(i) All information required by numbers 1 through 4, above, for the first disclosure
during the accounting period;

(ii) The frequency or number of disclosures made during the accounting period; and

(iii)The date of the last disclosure during the accounting period.

B. PHI Excluded From Accounting
Excluded from the accounting requirements are disclosures made:

1. Prior to April 14, 2003.

2. For treatment, payment, and healthcare operations.

3. To the patient/client themselves.

4. Pursuant to a patient/client’s authorization.

5. To people involved in the patient/client’s care.

6. To notify a family member, or other person responsible for the patient’s care, of the
patient’s location or condition.

7. To law enforcement or correctional institutions as provided in state law.

8. For national security or intelligence purposes.

9. For certain marketing purposes (please also see “Marketing Use Policy,” Privacy

C. Examples
Examples of disclosures which require accounting include, but are not limited to:

1. Child or Elder Abuse as required by state law;

2. Cancer Registry required by state and federal law;

3. Communicable Disease/Public Health Reporting required by state law;

4. Coroner, Medical Examiner or Death Registry as required by state law;

5. Court Orders as required by state law;

6. Department of Transportation required under state law;

7. Licensing agencies’ boards;

8. Erroneous Releases of Information subject to incident reporting

9. Some research data pulls for Faculty Departments. These data pulls require
compliance with the University of Wisconsin Privacy Policies for Research.

Please see the UWMF “Release & Disclosure of PHI” Policy / Privacy 001, for a grid of
disclosures and notations regarding whether the disclosure is subject to accounting.

D. No Limitation as to Form
Disclosures are not limited to hard-copy information. Disclosures requiring accounting
can be made in any manner that divulges PHI, including by verbal or electronic modes.

E. Forms
Disclosures are accounted for using a variety of forms or mechanisms to ensure accurate
and complete accounting of disclosures. UWMF employees use the following means to
account for disclosures:

1. Report for Accounting of Disclosure Form, which is a form available on the UWMF
Intranet under “HIPAA Resources;”

2. When faxing PHI, a fully completed UWMF fax cover sheet;

2. A Tracking Log which may be maintained in each patient’s chart. See “Tracking
Log” form, attached to this policy).

3. Computerized tracking systems to become available in 2005 via the Epic System,
which will sort by patient name and date.

F. Patient Request For Accounting

1. A patient is required to request an Accounting of Disclosures in writing and
addressed to the Director of Health Information Management (“HIM”). Clinic staff
route all such requests to the Director of HIM within five (5) days receipt of any such
written request.

2. The HIM Department will fulfill all valid and written requests for an Accounting of
Disclosures within sixty (60) days receipt of such request. The HIM Department may
request one, thirty (30) day extension of time if such request is made within the
original sixty (60) day period and such request is made via written notice to the
patient which contains a statement of the reason(s) for the delay and the expected
completion date.

3. The accounting report shall account for disclosures made for a period of up to six (6)
years before the date of the patient’s request, but in no event before April 14, 2003.

4. UWMF retains for a period of six (6) years the patient’s request, a copy of the written
accounting provided to the patient, and shall note the title of the person and/or
department receiving and responsible for processing the accounting requests.

5. A patient/client may authorize in writing that the accounting of disclosures be
released to another individual or entity. The request is accepted only in the form of a
clearly and completely executed identify all information required to carry out the
request (name, address, phone number, etc.)

6. The UWMF provides the accounting to the patient/client at no charge, unless the
patient makes more than one request within a twelve-month period. A reasonable fee
is then charged for each such additional request and the patient is informed of this fee
in advance of satisfying the additional request. The patient is then given an
opportunity to withdraw or modify the request.

G. Suspension of Right
UWMF suspends the patient’s right to receive an accounting of any disclosures which
have been made to a health oversight agency or law enforcement official if a written
request for such suspension of the right is made by the agency or official. The following
conditions are met before a suspension of the right takes place:

1. The agency or official makes a written request of suspension which states that an
accounting to the patient is reasonably likely to impede the agency’s activities. All
such requests are routed to the Director of HIM;

2 The written request specifies the time period for which the suspension is to be
required; and

3. If the agency or official request is made orally, the UWMF documents the statement,
including the identity of the agency or official making the request and the statement,
and the UWMF limits the oral temporary suspension to no longer than thirty (30)
days from the date of the oral statement, unless a written statement is submitted
during that same period of time.

Once conditions #1 through 3 are met, UWMF suspends the patient’s right to an
accounting of disclosures subject to the official statement(s), as noted above. UWMF
business associates make available the information required to provide an accounting of

H. Documentation:

1. UWMF documents and retains the title of the person or office responsible for
receiving and processing request for an accounting of disclosures for six years from
the date of creation or the date when it was last in effect, whichever is later.

2. UWMF retains the written or electronic copy of the accounting that is provided to the
patient or his / her designated individual for six years from the date of creation, or the
date when it was last in effect, whichever is later.

3. UWMF documents and retains the information required to be included in an
accounting of disclosures for six years from the date of creation or the date when it
was last in effect, whichever is later.

IV. References

 AHIMA Practice Brief: Accounting & Tracking Disclosures of PHI
 HIPAA Collaborative of Wisconsin (HIPAA COW)

State Preemption Issues: Section 51.30(4)(e) of Wisconsin Statutes requires notation each
time written information is released from the individual’s record and gives the individual access
to the notations. The statute does not mention the address of the person to whom the information
was released and does not mention a time limit. Section 146.82(3)(c) of Wisconsin Statutes
requires physicians and optometrists to record disclosures and track information. Section
146.83(3) of Wisconsin Statutes requires providers to note inspections of patient records made
by the patient or person authorized by the patient.

Related Policies

 UWMF “Release & Disclosure of PHI” Policy
 UWMF “Marketing Use” Policy
 UW Madison “Accounting of Disclosures Policy”
 Report for Accounting of Disclosures
 Disclosure Tracking Log

V. Author & Review

Sponsor: UWMF HIPAA Steering

Author: Claudia Jane Sanders
Review: UWMF HIPAA Steering

Committee Approval: UWMF HIPAA Steering

Supplement - Final
Senior Management Committee Date: June 21, 2004



Patient/Client Name: MR#:


Name of

Address (If


Purpose of




(Use the above section as a complete record or to record those disclosures made w/o an authorization complete
fully if requested by patient/client or legal representative)


Requested By
(Individual/Legal Rep)


Date Range Requested

Staff Member
Completing Request

Date Provided

(Use the above section to document accounting requests when an accounting is provided to the patient/client.)


Auth Type: How was request received
Purpose of Disclosure: CC = Continuing Care; INS = Insurance Processing; LEG = Legal Issue; Explain any