H51more i DEPARTMENT OF HEALTH HUMAN SERVICES OFFICE OF THE SECRETARY 6 Voice - (212) 264-3313, (soc) 363-1019 Of?ce for Civil Rights, Region Prawn: Too - {212) 264-2355 Jacob Javits Federal Building (FAX) - {212] 264-3039 hits govrocn' 26 Federal Plaza, Suite 3312 New York, NY 10273 cm 2 5 um Privacy Of?cer CVS Caremark One CV3 Drive Woonsocket, RI 02395 OCR Transaction Number: 11-128211 On June 1, 2011 the US. Department of Health and Human Services (HHS), Office for Civil Rights (OCR), Region It received a compiaint alleging that CV8, the covered entity, has violated the Federal Standards for Privacy of individually Identifiable Health Information {45 C.F.R. Parts 160 and 164, Subparts A and E, the Privacy Rule). Speci?cally, the complainant, alleges that on May 21, 2011, awor .- i - the CVS ore numr a - 4, disclosed her protected health information (PHI) to a third party, [a family member] when the worldorce member gave the third party a record of all of her prescription medications without her authorization. This allegation could re?ect a violation of 45 C.F.R. 164.510 and OCR enforces the Privacy, Security, and Breach Noti?cation Rules, and also enforces the Federal civil rights laws which prohibit discrimination in the deiivery of health and human services because of race, color, national origin, disability, age, and under certain circumstances, sex and religion. Pursuant to the Privacy Rule, a covered entity may not use or disclose protected health information (PHI) except as permitted or required by the Privacy Rule. As long as an individual does not object, a covered entity is allowed to share or discuss the individual?s health information with the individual?s family, friends, or others involved in the individuals care or payment for their care. The covered entity may ask the individual?s permission, may tell the individual that the covered entity plans to discuss the information and give the individual an opportunity to object, or may decide, using the covered entity?s professional judgment, that the individual does not object. However, in any of these cases, the covered entity may discuss o_n y the information that the person involved needs to know about the individual?s care or payment for their care. The minimum necessary provision ofthe Privacy Rule also requires the covered entity to limit access to protected health information by identifying the persons or classes of persons within the covered entity who need access to the information to carry out theirjob duties, the categories or types of protected health information needed, and conditions appropriate to such access. {bli?i?ltCl Page 2 IPrivacy Of?cer Finally, a covered entity must provide a process for individuals to make complaints concerning the covered entity?s policies and procedures required by the Privacy Rule or its compliance with such policies and procedures or with the requirements of the Privacy Rule. 45 C.F.R. 164.530 (dill). In this matter, the complainant atleges that the complainant?s was impennissibiy disclosed to a member of the complainant's family or to an acquaintance of the complainant or that the complainant?s was otherwise impermissiny used by an employee of CVS. Pursuant to its authority under 45 CPR. 160.3043) and OCR has determined to resolve this matter informally through the provision of technical assistance to CVS. To that end, OCR has enclosed material explaining the Privacy Rule provisions related to Disclosures to Famin and Friends, the Minimum Necessary Requirement, and Reasonable Safeguards. It is our expectation that you will review these materials closely and share them with your staff as part of the Health insurance Portability and Accountability Act (HIPAA) training you provide to your workforce. It is also our expectation that you will assess and determine whether there may have been an incident of noncompliance as alleged by the complainant in this matter, and, if so, to take the steps necessary to ensure such noncompliance does not occur in the future. Please contact OCR if you need further information regarding the allegations in this matter. Should OCR receive a similar allegation of noncompliance against CVS, OCR may initiate a formal investigation of that matter. Based on the forgoing, OCR is closing this case without further action, effective the date of this letter. determination as stated in this letter applies only to the allegations in this complaint that were reviewed by OCR. Under the Freedom of Information Act, we may be required to release this letter and other information about this case upon request by the public. in the event OCR receives such a request, we will make every effort, as permitted by law, to protect information that identi?es individuals or that, if reteased, could constitute a clearly unwarranted invasion of personal pnvacy. It you have any questions regarding this matter, please contact Cheylisia Edwards, Investigator, at {212) 264-4148 (Voice) or (212) 264-3039 DD). since y, Linda C. Colon Regional Manager Enclosures: Disclosures to Family and Friends The Minimum Necessary Requirement Reasonable Safeguards 512 Mi I or; . ted? 3? HEALTH DEPARTMENT OF HEALTH HUMAN SERVICES OFFICE OF THE SECRETARY voioe - (212:. 234-3313. {soc} 363-1019 oniee for Civil Rights, Region TDD - (212) 264-2355 Jacob Javits Federal Building (FAX) - (212) 264?3039 26 Federal Plaza, Suite 3312 hugrrwemhhe gcvl?ocn? New York, NY 10273 2 6 2012 (blt?liblti?ltcl OCR Transaction Number: 11-128211 ibiioitbitoim Dear On June 1. 2011. the US. Department of Health and Human Services (HHS). Office for Civil Rights (OCR), Region It received your complaint alleging that CV8. the covered entity. has violated the Federal Standards for Privacy of Individually Identifiable Health Information (45 C.F.R. Parts 160 and 164. Subparts A and E, the Privacy Rule). Specifically. you allege that on May 21. 201 a workforce member at the covered isclosed your protected health information tow a third party [a family member], when the workforce member gave the third party a record of all of your prescription medications without your authorization. This allegation could re?ect a violation of 45 CFR. 164.502ta). 164.510 and Thank you for bringing this matter to attention. Your complaint plays an integral part in OCR's enforcement efforts. OCR enforces the Privacy. Security. and Breach Notification Rules. and also enforces the Federal civil rights laws which prohibit discrimination in the delivery of health and human services because of race. color. national origin, disability. age. and under certain circumstances. sex and religion. A covered entity may not use or disclose protected health information except as permitted or required by the Privacy Rule. As long as an individual does not object. a covered entity is aflowed to share or discuss with the individual?s family. friends. or other persons identi?ed by the individual the protected health information that is directly relevant to such person?s involvement with the individual?s care or payment for ca re. The covered entity may ask the individual's permission. may tell the individual that the covered entity pians to discuss the information and give the individual an opportunity to object. or may decide. using the covered entity?s professionatjudgment. that the individual does not object However. in any of these cases. the covered entity may discuss o_nly, the information that the person involved needs to know about the individual?s care or payment for their care. {hlt?l Page2? The minimum necessary provision of the Privacy Rule also requires the covered entity to limit access to protected health information by identifying the persons or classes of persons within the covered entity who need access to the information to carry out their job duties. the categories or types of protected health information needed, and conditions appropriate to such access. Finally, a covered entity must provide a process for individuals to make complaints concerning the covered entity's policies and procedures required by the Privacy Rule or its compliance with such policies and procedures or with the requirements of the Privacy Rule. 45 C.F.R. 164.530 - We have carefully reviewed your complaint against CVS and have determined to resolve this matter informally through the provision of technical assistance to CVS. Should OCR receive a similar allegation of noncompliance against CV8 in the future, OCR may initiate a formal investigation of that matter. Based on the foregoing, OCR is closing this case without further action, effective the date of this letter. OCR's determination as stated in this letter applies only to the allegations in this complaint that were reviewed by OCR. Under the Freedom of Information Act, we may be required to release this letter and other information about this case upon request by the public. In the event OCR receives such a request, we will make every effort, as permitted by law, to protect information that identifies individuals or that, if released, could constitute a clearly unwarranted invasion of personal privacy. If you have any questions regarding this matter. please contact Cheylisia Edwards, Investigator, at (212} 264-4148 (Voice) or (212)