f1 mm} i DEPARTMENT or HEALTH HUMAN SERVICES Of?ce of the Seme Kw: Voice - {617) 565-1340. (800) 368-1019 Of?ce for Civil Rights, Region TDD - (617} 565-1343. (800) 537-?697 Government Center :?ax (61 7) J.F. Kennedy Federal Building, 2: MW. $ng . Room 1375 . FEB 2 2014 Boston. MA 02203-0002 Our Reference number: 01-]3-155468 Dear . On February 6, 2013, the US. Department of Health and Human Services (HHS), Of?ce for Civil Rights (OCR), received your complaint alleging that the Department of Veterans Affairs (VA), the covered entity, has violated the Federal Standards for Privacy of Individually Identi?able Health Information (45 C.F.R. Parts 160 and 164, Subparts A and E, the Privacy Rule). Speci?cally, you allege that, on October 26, 2012, you received a large package of another veteran?s protected health information (PHI). In addition, you allege that on February 5, 2013, the VA mailed your PHI to a private physician. This allegation could re?ect a violation of 45 C.F.R. 164.502(a) and . Thank you for bringing this matter to attention. Your complaint piays an integral part in I enforcement efforts. OCR enforces the Privacy, Security, and Breach Noti?cation Rules, and also enforces 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. The Privacy Rule allows health care providers and health plans to share protected health information (PHI) for permitted purposes using the mail or fan, as long as they use reasonable and appropriate administrative, technical, and physical safeguards to protect the privacy of the PHI. 45 CPR. These safeguards may vary depending on the mode of communication used. For example, when faxing PHI to a telephone number that is not used regularly, a reasonable safeguard may involve a covered entity ?rst con?rming the fax number with the intended recipient of the fax. We have carefully reviewed your complaint against the VA and have determined to resolve this matter informally through the provision of technical assistance to the VA, Should OCR receive a similar allegation of noncompliance against the VA in the future, OCR may initiate a formal investigation of that matter. Basedon the foregoing, OCR is closing this case without further action, effective the date of this OCR Transaction Page No.: 2 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 released, could constitute a clearly unwarranted invasion of personal privacy. If you have any questions regarding this matter, please contact Erin Walker, Investigator, at Erin.Walker@hhs.gov, or (617) 565-1351 (Voice), (800) 537-7697 (TDD). Thank you for bringing this matter to our attention. Sincerely, WW Susan M. Pezzullo Rhodes Acting Regional Manager DEPARTMENT OF HEALTH HUMAN SERVICES 0m? 0w? 3m? Voice - (617} 565-1340. (800} 363-1019 Of?ce for Civil Rights, Region I TDD Government Center Fax - (617) 565-3809 J.F. Kennedy Federal Building. FEB 2 0 2014 Room 1375 Boston, MA 02203-0002 Ms. Andrea Wilson, RHIA, CIPP, CIPPIG VHA Privacy Implementation Coordinator Information Access and Privacy Of?ce- 10P2C1 Department of Veterans Affairs-Veterans Health Administration 810 Vermont Ave, NW Washington DC 20420 Our Reference number: 01-13-15 5468 Dear Ms. Wilson: On April 15, 2013, the Department of Health and Human Services (HHS), Of?ce for Civil Rights (OCR), Region I received a complaint alleging that the Department of Veteran Affairs (VA), the covered entity, has violated the Federal Standards for Privacy of Individually Identi?able Health Information (45 f? Parts 160 and 164, Subparts A and E, the Privacy Rule). Speci?cally, the complainant, alleges that, on October 26, 2012, he a ge package of another veteran?s protected health information (PHI). In addition, received {b?mimm'ici alleges that on February 5, 2013, the VA mailed his PHI to a private physician in error. This legation could re?ect a violation of 45 C.F.R. 164.502(a) and OCR enforces the Privacy, Security, and Breach Noti?cation Rules, and also enforces Federal civii 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. Generally, the Privacy Rule permits a covered entity to make disclosures of protected health information (PHI) for a pennitted purpose, through a variety of means, such as by mail or facsimile machine, as long as the covered entity, when doing so, uses reasonable and appropriate administrative, technical, and physical safeguards to protect the privacy of the PHI. See 45 CPR. These safeguards may vary depending on the mode of conununication used. For example, when faxing PHI to a telephone number that is not used regularly, a reasonable safeguard may involve a covered entity ?rst con?rming- the fax number with the intended recipient of the fax. In this matter, the complainant alleges that PHI was impermissiny disclosed either through the mail or by fax. Pursuant to its authority under 45 CPR. 160.304(a) and OCR has determined to resolve this matter informally through the provision of technical assistance to VA. To that end, OCR has enclosed a checklist of reminders on how to safely use the mail or fax machines when sending PHI. Page No; 2, OCR Transaction Number: 01-13-155468 You are encouraged to review these materials closely and to share them with your staff as part of the Health Insurance Portability and Accountability Act (HIPAA) training you provide to your workforce. You are also encouraged to 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 the VA 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 e?ort, as permitted by law, to protect infonnation that identi?es individuals or that, if released, could constitute a clearly unwarranted invasion of personal privacy. If you have any questions regarding this matter, please contact Erin Walker, Investigator, at (617) 565-1351 (Voice), (800) 537-7697 (I DD). Sincerely, - Susan M. Pezzullo Rhodes Acting Regional Manager Enclosure: Checklist f1 mm} i DEPARTMENT or HEALTH HUMAN SERVICES Of?ce of the Seme Kw: Voice - {617) 565-1340. (800) 368-1019 Of?ce for Civil Rights, Region TDD - (617} 565-1343. (800) 537-?697 Government Center :?ax (61 7) J.F. Kennedy Federal Building, 2: MW. $ng . Room 1375 . FEB 2 2014 Boston. MA 02203-0002 Our Reference number: 01-]3-155468 Dear On February 6, 2013, the US. Department of Health and Human Services (HHS), Of?ce for Civil Rights (OCR), received your complaint alleging that the Department of Veterans Affairs (VA), the covered entity, has violated the Federal Standards for Privacy of Individually Identi?able Health Information (45 C.F.R. Parts 160 and 164, Subparts A and E, the Privacy Rule). Speci?cally, you allege that, on October 26, 2012, you received a large package of another veteran?s protected health information (PHI). In addition, you allege that on February 5, 2013, the VA mailed your PHI to a private physician. This allegation could re?ect a violation of 45 C.F.R. 164.502(a) and . Thank you for bringing this matter to attention. Your complaint piays an integral part in I enforcement efforts. OCR enforces the Privacy, Security, and Breach Noti?cation Rules, and also enforces 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. The Privacy Rule allows health care providers and health plans to share protected health information (PHI) for permitted purposes using the mail or fan, as long as they use reasonable and appropriate administrative, technical, and physical safeguards to protect the privacy of the PHI. 45 CPR. These safeguards may vary depending on the mode of communication used. For example, when faxing PHI to a telephone number that is not used regularly, a reasonable safeguard may involve a covered entity ?rst con?rming the fax number with the intended recipient of the fax. We have carefully reviewed your complaint against the VA and have determined to resolve this matter informally through the provision of technical assistance to the VA, Should OCR receive a similar allegation of noncompliance against the VA in the future, OCR may initiate a formal investigation of that matter. Basedon the foregoing, OCR is closing this case without further action, effective the date of this OCR Transaction Page No.: 2 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 released, could constitute a clearly unwarranted invasion of personal privacy. If you have any questions regarding this matter, please contact Erin Walker, Investigator, at Erin.Walker@hhs.gov, or (617) 565-1351 (Voice), (800) 537-7697 (TDD). Thank you for bringing this matter to our attention. Sincerely, WW Susan M. Pezzullo Rhodes Acting Regional Manager DEPARTMENT OF HEALTH HUMAN SERVICES 0m? 0w? 3m? Voice - (617} 565-1340. (800} 363-1019 Of?ce for Civil Rights, Region I TDD - (517) 565-1343. (soc) ear-rear Government Center Fax - (617) 565-3809 J.F. Kennedy Federal Building. FEB 2 0 2014 Room 1375 Boston, MA 02203-0002 Ms. Andrea Wilson, RHIA, CIPP, CIPPIG VHA Privacy Implementation Coordinator Information Access and Privacy Of?ce- 10P2C1 Department of Veterans Affairs-Veterans Health Administration 810 Vermont Ave, NW Washington DC 20420 Our Reference number: 01-13-15 5468 Dear Ms. Wilson: On April 15, 2013, the Department of Health and Human Services (HHS), Of?ce for Civil Rights (OCR), Region I received a complaint alleging that the Department of Veteran Affairs (VA), the covered entity, has violated the Federal Standards for Privacy of Individually Identi?able Health Information (45 C.F.R. Parts 160 and 164, Subparts A and E, the Privacy Rule). Speci?cally, the complainant, ibli53=ibliiltcl that, on October 26, 2012, he received a large package of another veteran?s protected health information (PHI). In addition, alleges that on February 5, 2013, the VA mailed his PHI to a private physician in error. . legation could re?ect a violation of 45 C.F.R. 164.502(a) and OCR enforces the Privacy, Security, and Breach Noti?cation Rules, and also enforces Federal civii 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. Generally, the Privacy Rule permits a covered entity to make disclosures of protected health information (PHI) for a pennitted purpose, through a variety of means, such as by mail or facsimile machine, as long as the covered entity, when doing so, uses reasonable and appropriate administrative, technical, and physical safeguards to protect the privacy of the PHI. See 45 CPR. These safeguards may vary depending on the mode of conununication used. For example, when faxing PHI to a telephone number that is not used regularly, a reasonable safeguard may involve a covered entity ?rst con?rming- fax number with the intended recipient of the fax. In this matter, the complainant alleges that PHI was impermissiny disclosed either through the mail or by fax. Pursuant to its authority under 45 CPR. 160.304(a) and OCR has determined to resolve this matter informally through the provision of technical assistance to VA. To that end, OCR has enclosed a checklist of reminders on how to safely use the mail or fax machines when sending PHI. Page No; 2, OCR Transaction Number: 01-13-155468 You are encouraged to review these materials closely and to share them with your staff as part of the Health Insurance Portability and Accountability Act (HIPAA) training you provide to your workforce. You are also encouraged to 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 the VA 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 e?ort, as permitted by law, to protect infonnation that identi?es individuals or that, if released, could constitute a clearly unwarranted invasion of personal privacy. If you have any questions regarding this matter, please contact Erin Walker, Investigator, at (617) 565-1351 (Voice), (800) 537-7697 (I DD). Sincerely, - Susan M. Pezzullo Rhodes Acting Regional Manager Enclosure: Checklist