511'? m: . 11,4? DEPARTMENT OF HEALTH 8: HUMAN SERVICES OFFICE OF THE SECRETARY voice -{212} 264-3313, (soc) ass-1019 omen for Civil Rights, Region II TDD- (212} 254-355. (soc) sat-rest Jacob Javits Federal Building (FAX) (212) 25445039 26 Federal Plaza, Suite 3312 New York, NY were 1 5 2013 Dear OCR Transaction Number: 12446465 On July 25, 2012, the us. Department of Health and Human Services (HHS), Of?ce for Civil Rights (OCR), Region received your complaint alleging that CVS Pharmacy store located at 8970 S. Meridian Street, lndianapolis, IN 46217 (CV5), the covered entity, has violated the Federal Standards for Privacy of individually Identi?able Health Information (45 C.F.R. Parts 160 and 164, Subpalts A and E, the Privacy Rule). The complaint was forwarded to the Re ion ll offi for consideration. Speci?cally, you allege that. on July 23. 2012, an estranged acquaintance and an employee of CVS, disclosed your me real condition to a mutual acquaintance of your girlfriend. This allegation could re?ection a violation of 45 C.F.R. 164.510 and 164.530tc). Thank you for bringing this matter to OCR's attention. pad in enforcement efforts. Your complaint plays an integral 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'raoe, 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 I 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 ind ividual'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 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_nly 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 Page 2 of 2- {bliEiliblii'iiCl persons within the covered entity who need access to the information to carry out their job duties. the categories or types of protected hearth 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 CPR. 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 lnfonnation 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 released, could constitute a clearly unwarranted invasion of personal privacy. Should you have any questions regarding this matter, please contact Robert Chilila, Investigator. by email at or by telephone at (212) 264-8900 (Voice). or (212) 264-2355 (TDD). Thank you for bringing this matter to our attention. Since ly, a C. Colon Regional Manager and Cl 1' $19 DEPARTMENT OF HEALTH a HUMAN SERVICE OFFICE OF THE SECRETARY is Voice - {212) 264-3313, {coo} ass-1019 case he can Rights, Region II TDD - {212; 254.2355. {son} 537-?69? Jacob Javits Federal Building (FAX) 421212545039 26 Federal Plaza, Suite 3312 New iterator 10m {Uli?ltbliili?l Director 160 and 164, SubpartsA and E, the Privacy 1 5 2013 orrnation Governance and Privacy 9501 Shea Scottsdale, AZ 85260-8719 OCR Transaction Number: 12446465 {bltfit?i Dear On July 25, 2012, the U.S. Department of Health and Human Services (HHS), Of?ce for Civil Rights (OCR), Region V, received a complaint alteging that CVS Pharmacy store located at 8970 S. Meridian Street, Indianapolis, IN 46217 (CV8), the covered entity, has violated the Federal Standards for Privacy of individually Identi?able Health Information (45 C.F.R. Parts I Region ilof?celformg ?id?ta?utl' .Speci?cally, July 231 an estranged acqual disclosed her medical condition to a mutual acquaintance of her girlfriend. This allegation could re?ection a violation of 45 C.F.R. 164.510 and OCR enforces the Privacy, Security, and Breach Noti?cation Ruies, and also enforces the Federal civil rights iaws which prohibit discrimination in the delivery of health and human services because of race, color, nationai 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 bythe 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 individuai's family, friends, or others involved in the individuai's care or payment for their care. The covered entity may ask the individual?s permission, may teli 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 ind ivid does not object. However, in any of these cases, the covered entity may discuss my the information that the person involved needs to know about the individ uai's care or paymentfor 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 information to carryI out their job duties, the categories or types of protected heaith information needed, and conditions appropriate to such access. {tlt?ilblE?i?ltcl Page 2 on- _Finally, a covered entity must provide aprocess 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 CPR. . 164.530 in this matter, the complainant alleges that the complainant?s 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 imperrnissibly used by an employee of CVS. Pursuant to its authority under 45 C.F.R. 160.304(a) and OCR has determined to resolve this matter infonnaliy through the provision of technical assistance to CVS. To that and, 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 closer and share them with your staff as part ofthe Health insurance Portability and Accountability Act (HIPAA) training you provide 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 ailegation of noncompliance against CV8 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 inforrnaticn that identi?es individuals or that, If released, could constitute a clearly unwarranted invasion of personal pnvaoy. Should you have any questions regarding this matter, please contact Robert Chirila, investigator, by email at or by telephone at (212) 264-8900 (Voice), or (212) 264-2355 (TDD). Thank you for bringing this matter to our attention. Sincerely, gig/Fr da (3. Colon Regional Manager Enclosures: Disclosures to Fernin and Friends The Minimum Necessary Requirement Reasonable Safeguards