more {?it on HEALTH Homo OFFICE on THE secssraav ti ?s Voice - (212) 264-3313, (soc) 383?1019 Of?ce for Civil Rights, Region II as?, TDD ?212) 2644355. cooler-res? Jacob Javits Federal Building - i212) 264-3Cl39 26 Federal Plaza, Suite 3312 New York, NY In 19 ton Re: OCR Transaction Number: 13-156464 Dear {clinic} On February 25, 2013, the US. Department of Health and Human Services (HHS), Of?ce for Civil Rights (OCR), Region 2 received your complaint alleging that CVS Pharmacy, 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 February 24, 2013, CVS Pharmacy gave your medication to your sister, Iibl'i?illtliillcl This allegation could reflect a violation of 45 C.F.R. 164.510 and 164.530ic). 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 family. 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 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 the information that the person involved needs to know about the individuals 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 3008 SS. Page 2 of 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 of the Privacy Rule. 45 C.F.R. 164.530 (dim. We have carefully reviewed your complaint against CVS Pharmacy and have determined to resolve this matter informally through the provision of technical assistance to CVS Pharmacy. Should OCR receive a similar allegation of noncompliance against CVS Pharmacy in the future, OCR may initiate a formal investigation of that matter. Based on the foregoing, OCR is closing-the 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 released, could constitute a clearly unwan?anted invasion of personal privacy. - if you have any questions regarding this matter, please contact Robert Chirila, Investigator, by email at robert.chirila@hhs.gcv or by telephone at (212) 254-3900 (Voice), or (212) 264-2355 (TDD). Thank you for bringing this matter to our attention Sincer y, (If a C. Colon Regional Manager I . hie-5'5? CH DJ OFFICE OF THE SECRETARY Of?ce for {Evil Rights, Region 1] Jacob Javils Federal Building 26 Federal Plaza, Suite 3312 New York, NY 10278 DEPARTMENT OF HEALTH 8: SERWCES s? i voice - (212} 264-3313, (soc) soc-11319 "charm: TDD - (212)264-2355, (coo) cor?res? {Faro - (212) moose Weenies: creamer-:01 Director of information Governance and Privacy CVS Pharmacy 1 9 9501 Shea Scottsdale, AZ 35260-6719 Re: OCR Transaction Number: 13456464 Dear On February 25, 2013, the U.S. Department of Health and Human Services (HHS), Of?ce for Civil Rights (OCR), Region 2 received a complaint alleging that (We Pharmacy store located at Central Avenue, Hartsdale, New York, the covered entity, has violated the Federal Standards for Privacy of Individually identi?able Health Information 45 C.F.R. 0 and 164, Subparts A and E, the Privacy Rule). Speci?cally, [Pita-{biting i(the com lainant, alleges that on February 24, 2013, CVS Pharmacy gave her medication to her sister lill?jliblm I This allegation could reflection a violation of 45 CPR. meow (D), and 1 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. 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_l_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 requlres 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 Page 2 of 9_ thii?ithitiit?i with such policies and procedures or with the requirements of the Privacy Rule. 45 CPR. 164.530 In this matter1 the complainant alleges that the complainant's PHI was imperrnissibly disclosed to a member of the complainant's family or to an acquaintance of the complainant or that the complainant?s PHI was otherwise impermissiny used by an employee of CVS Pharmacy. Pursuant to its authority under 45 C.F.R. 160.304ta) and OCR has determined to resolve this matter informally through the provision of technical assistance to CVS Pharmacy. 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 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 Pharmacy 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. determination as stated in this letter applies only to the allegations in this complaint that were reviewed by OCR. Under the Freedom of Infon'nation 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 bylaw, to protect information that identifies individuals or that, if released, could constitute a steady unvvarranted invasion of personal privacy. If If you have any questions regarding this matter, please contact Robert Chirila, Investigator, by email at robert.chirita@hhs.gov or by teiephone at (212) 264-3900 (Voice), or (212) 264- 2355 (TDD). Thank you for bringing this matter to our attention nda C. Colon Regional Manager Sin r? Enclosures: Disclosures to Family and Friends The Minimum Necessary Requirement Reasonable Safeguards