College of Medicine

Privacy Policy & Procedure Manual

Operational Guidelines

Complete Text, Including Table of Contents

Policy Name

Last Revised

1.

Relationship of University of Florida Components and Entities Explained

2.

Maintaining Confidentiality of Health Information
  Confidentiality Statement  Form

3.

De-Identification of Protected Health Information
  (Moved from Privacy Management - 11/01/2006)

4.

Reporting, Investigating, & Responding to Privacy Violations
   - The Investigation Process
   - Notification of Individuals
   - Disclosures By Whistleblowers
   - Incidental, Accidental, and Intentional Disclosures

Incident Report - Protected Health Information Form
   Fillable Form
Incident Report - Personal Identification Information  Form
   Fillable Form
Recommended Corrective Actions and Sanctions - Staff
Recommended Corrective Actions and Sanctions - Students
Reporting and Investigation Flowchart - PHI

5.

Health Information and Record Management Policy
(See next section for Retention & Storage Guidlines)
   - Using and Disclosing Health Information
   - Management of Active Records
   - Storage and Security of Active Records
   - Removing Records from Patient Care Areas
   - Duplicating / Photocopying Records
   - Recovery of Lost and/or Damaged Paper Records

Designated Record Set Matrix

6.

Retention, Archiving, & Disposal of Patient Information
   - Retention of Records
   - Storing Inactive Records
   - Disposal and Destruction of Records

Record Inventory Log  Form
Record Destruction Log Form
UF Records Disposition Request Form

 7.   Patient's Rights

a

Notice of Privacy Practices
Notice of Privacy Practices (English) (En Español)
Acknowledgment of Receipt of NPP (English) (En Español)

b

Access to Records
Authorization to Use and Disclose PHI (Form)

c

Restrictions of Uses and Disclosures
Request for Special Privacy Protections(Form)

d

More Confidential Communications
Request for Special Privacy Protections (Form)

e

Amendment or Correction of Records
Request for Amendment of a Medical Record (Form)
Response to Request for Amendment (Form)

 8.  Uses and Disclosures of PHI

a

General Rules
- What is PHI?
- Permitted Uses and Disclosures
- Purchasing, Developing, Upgrading, or Enhancing Products
  or Systems That Use PHI
- Responding to Agencies Claiming Exemption from HIPAA
- Responding to Media Requests for Patient Information

b

Marketing and Fundraising

c

Subpoenas, Court Orders, and Attorney Requests
- Records for Depositions
- UF Gainesville - Processing Requests for Records
- UF Jacksonville - Requests for Records
- Requests for Super-Confidential Records (Mental Health,
  Substance Abuse, STD's/HIV/AIDS)

d

Treatment, Payment, Operations

e

Family Members and Friends

f

Research

9.

Authorizations to Use or Disclose PHI
Authorization to Use or Disclose PHI Form
Authorization to Use or Disclose PHI via Electronic Communications  Form
  Alert for Electronic Communication Form
Authorization to Use or Disclose PHI for Marketing, Fundraising, or Public Relations Form

10.

Accounting for Disclosures
Request for Accounting of Disclosures (Form)

11.

Verification of Identity and Authority

12.

Minimum Necessary Rule

13.

Complaints
Privacy Complaint Form(Form)

14.

Security: General Privacy Safeguards

15.

Security of Personal Portable Data Devices
Including PDA's, dictation equipment, laptop or notebook computers, blackberry devices, cell phones, camera phones, digital cameras, video recorders, and similar devices

 16.  Security of E-PHI (Electronic Protected Health Information)

a

Electronic Databases

b

Electronic Mail

c

Video-conferences and Audio-conferences

 17.  Security of Other PHI

a

Verbal and Telephone Communications
 - Use of Interpreters
 - Use of Telephone Devices for Hearing Impaired

b

Faxing
Sample Fax Cover Sheet - Form

18.

Education and Training
 - Level 1: General Awareness
 - Level 2: Policies & Procedures
 - Level 3: Role-Specific