IV ?1 qr? 0? ?um. 5&0 DEPARTMENT OF HEALTH Er. HUMAN SERVICES OFFICE OF THE SECRETARY h, Voice - (212) 264-3313, (330] 368-1019 Of?ce for Civil Rights, Region 1] Ram?: TDD - (212) 2644355, (300)513-7697 Jacob avits Federal Building - {212) 254-3039 26 Federal Plaza, Suite 3312 swallowing! New York, NY 10278 {bil?llbiliil?i WY 0 9 1813 OCR Transaction Number: 13458349 Dear On April 8, 2013. the U5. Department of Health and Human Services HHS Of?ce for Civil Rights (OCR), Region 2 received your complaint alleging that I VA Medical Center 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 March 26, 2013. your sister?in-iaw, an employee of accessed your medical record to obtain information regarding yourtreatment appointments. 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 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 allowed 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 persons involvement with the individuals 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 only 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 page 2 of 2_ job duties. the categories or types of protected health information needed. and conditions appropriate to such access. Finaliy, 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 and have determined to resolve this matter informally through the provision of technical assistance to Should OCR receive a similar allegation of noncompliance against 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 identities individuals or that. if released, could constitute a clearly unwarranted invasion of personal privacy. If you have any questions regarding this matter, please contact Robert Chirila, Investigator. by email at rcbert.chirila@hhs.gov or by telephone at (212) 264-8900 (Voice). or (212) 264-2355 (TDD). Sincerely. Regional Manager somenun OFFICE OF THE SECRETARY Of?ce for Civil Rights, Region II acoh avits Federal Building 26 Federal Plaza, Suite 3312 New York, NY 10278 DEPARTMENT OF HEALTH 8r. IRMAN SERVICES Voice -i{212} 254-3313, (300)368-1019 TDD - (212)264-2355. [800) 537-769? (FAN - (212) 264-3039 Woodrow! Ms. Andrea Wilson, CIPPIG ?m '5 VHA Privacy Implementation Coordinator my 0 lnfonnation Access and Privacy Of?ce- Deparlment of Veterans Affairs-Veterans ea Administration 810 Vermont Ave, NW - Washington DC 20420 OCR Transaction Number. 13-1 58349 Dear Ms. Wilson: On April 8, 2013, the US. Department of Health and Human Services (HHS). Of?ce for Civil Rights (OCR), Region 2, received a complaint alleging IVA Medical Center 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, the complainant, alleges that, on March 26, 2013, his sister-in-iaw, an emp'oyee accessed his medical record to obtain information regarding his treatment appointments. This allegation could re?ection a violation of 45 C.F.R. 164.502ia), 164.510 and 164.530ic). 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, coior, 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 hearth 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 the individual?s health information with the individuai?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 oppoitunity 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 ciasses 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. Page 2 of 9- Ms. Andrea Wilson 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 In this matter, the complainant alleges that the complainant?s was impen'nissibly disciosed 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 Pursuant to its authority under 45 C.F.R. 160.304(a) and OCR has determined to resolve this matter informally through the provision of technical assistance to 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 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 lnfon'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 by law, to protect information that identi?es individuals or that, if released, could constitute a clearly unwarranted invasion of personal pnvacy. If you have any questions regarding this matter, please contact Robert Chirila, Investigator, by email at or by telephone at (212) 264-3900 (Voice), or (212) 264-2355 (TDD). Sin Mai/? rnda C. Colbn Regional Manager ,2 Enclosures: Disclosures to Family and Friends The Minimum Necessary Requirement Reasonable Safeguards