o?gtI-ery?k DEPARTMENT OF HEALTH SERVICES OFFICE OF THE SECRETARY Voice - (212}264-3313. {300} 3634019 Of?ce for Civil Rights, Region II ran - (212) 254-2355 Jacob Javits Federal Building (FAX) - (212)254-3039 215 Federal Plaza, Suite 3312 goviocri New York, NY 10278 {bltEiiltbiiTitcl 0 8 Our reference number: 12433636 Dear Ebil?itbitntci On October 20, 2011, the U. S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR), Region It received your complaint alleging that New York Presbyterian Hospital, the covered entity. has violated the Federal Standards for Privacy of Individually Identifiable Health Information andior the Security Standards for the Protection of Electronic Protected Health Information (45 CPR. Parts 160 and 154, Subparts A, C, and E, the Privacy and Security Rules). Speci?cally, the complaint alleges that in September 2011, a staff member at New York Presbyterian Hospital accessed and disclosed your protected health information to your boyfriend without authorization. This allegation could reflect violations of 45 C.F.R. 164.502 and 164.530 and Thank you for bringing this matter to OCR's attention. Your complaint plays an integral part in OCR's enforcement efforts. OCR enforces the Privacy, Security, and Breach Noti?cation 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 allowed to share or discuss with the individual?s famity, friends, or other persons identified by the individual the protected health information that is directly relevant to such person?s involvement with the individual?s care or payment for 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 Page 2 {bli?libliilicl 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 gm the information that the person involved needs to know about the individual?s care or payment for their care. 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. 45 164.530 We have carefully reviewed your complaint against the New York Presbyterian Hospital and have determined to resolve this matter informally through the provision of technical assistance to New York Presbyterian Hospital. Should OCR receive a similar allegation of noncompliance against New York Presbyterian Hospital 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. 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 Anthony Zayas, Investigator, at (212) 264- 8595. Sincerely, Law a? da C. Colon Regional Manager 0? ?were it a DEPARTMENT OF HEALTH 3; SERVICES OFFICE OF THE SECRETARY Voice - (212) 264-3313, (300) 363-1019 Office for Civil Rights, Region II TDD - {212) 264-2355 Jacob Javits Federal Building (FAX) - (212) 254-3039 26 Federal Plaza, Suite 3312 gcvfoo'f New York, NY 10278 AUG 0 8 2912 Compliance Officer?rPrivacy Officer New York Presbyterian Hospital 525 East 68?" street Cape May Court House, New Jersey 03210 Our Reference Number: 12433636 Dear On October 20, 2011, the US. Department of Health and Human Services HHS Of?ce for Civil Rights (OCR), Region II, received a complaint from a patientalleging that New York Presbyterian Hospital, the covered entity, has violated the Federal Standards for Privacy of Individually Identifiable Health Information (45 C.F.R. Parts 160 and 164, Subarts A and E, the Privacy Rule). Specifically. the complaint alleges that in September 2011, a staff member New York Presbyterian Hospital accessed and disclosed a patient's protected health information to her boyfriend without authorization. This allegation could reflect violations of45 can. 164.502 and and 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. 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 individual's 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 ofthese cases, the covered entity may discuss gn_ y the information that the person involved needs to know about the individual?s care or payment for their care. 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 thelrjob duties, the categories or'types of protected health information needed, and conditions appropriate to such access, Page-2 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 ofthe Privacy Rule. 45 C.F.R. 164.530 In this matter, the complainant alleges that the complainant's PHI was impermissiny disclosed to a member of the complainant?s family or to an acquaintance of the complainant or that the complainant?s PHI was otherwise impen'nissibly used by an employee of New York Presbyterian Hospital. Thank you for your response dated July 26, 2012. Pursuant to its authority under 45 O.F.R. 160.304(a) and OCR has determined to resolve this matter informally through the provision of technical assistance to New York Presbyterian Hospital. To that end, OCR has enclosed material explaining the Privacy Rule provisions related to Disclosures to Family 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 ofthe Health Insurance Portability and Accountability Act 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 New York Presbyterian Hospital in the future. 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. 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 pnvacy. If you have any questions regarding this matter, please contact Anthony Zayas, Investigator, at (212} 264-8595.- Sincerely, Linda C. Colon Regional Manager Office for Civil Rights Enclosures: Disclosures to Family and Friends The Minimum Necessary Requirement Reasonable Safeguards