a. DEPAR - .t . . Voice (617) 555-1340, (300) 368-1019, TDD (617} 565- 1343, 300) 531-169? FAX (617) 565-3809. Of?ce for Civil Rights. Region I I 7 JFKFedenl Government Center loam-,MA onus-m: OCR Transaction Number: 13-1 59651 . 7" Dear ll ll 3 On May 1, 2013, the Department of Health and Human Services (HHS), Of?ce for Civil Rights (OCR), Region I received your complaint alleging that Department of Veterans Affairs, 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 the Veterans Health Administration impermissiny disclosed your protected health information to a congressman?s inquiry on your behalf regarding a claim. This allegation could re?ect a violation of 45 C.F.R. ?164.502(a) Thank you for bringing this matter to attention. Your complaint is an integral part of enforcement efforts. OCR enforces the Privacy, Security, and Breach Noti?cation Rules, and also 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 must maintain reasonable and appropriate administrative, technical, and physical safeguards to prevent intentional or unintentional use or disclosure of PHI in violation of the Privacy Rule and to limit its incidental use and disclosure pursuant to otherwise permitted or required use or disclosure. 45 CPR. For example, such safeguards might include shredding documents containing protected health information before discarding them, securing medical records with lock and key or pass code, and limiting access to keys or pass codes. We have care?illy reviewed your complaint against Veterans Health Administration and have determined to resolve this matter informally through the provision of technical assistance to Veterans Health Administration. Should OCR receive a similar allegation of noncompliance against Department of Veterans Affairs in the future, OCR may initiate a formal investigation of that matter. For your informational purposes, OCR has enclosed material regarding the Privacy Rule provisions related to Safeguards. Based on the foregoing, OCR is closing this case without ?thher 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 unwarranted invasion of personal privacy. If you have any questions regarding this matter, please contact Phil Lewis, Investigator, at (617) 565-1355 (Voice) or (617) 565-1343 (TDD). Sincerely, k. Peter Chan Regional Manager Mme- . '5 Voice {617) 565-1340, (Bill) 3634019, TDD 555- . - 2013 0mm Civil Rene. Revlon! JFK Federal Building, Room 1375 Government Center Boom.m02203-0M2 libuei?ibjmici IRI-IIA, CIPP, VHA Privacy Implementation Coordina Information Access and Privacy Of?ce- I Department of Veterans Affairs-Veterans Health Administration 810 Vermont Ave., NW Washington DC 20420 Re: 13-159651 Deg,I (manners) On May 1, 2013, the US. Department of Health and Human Services (HHS), Of?ce for Civil Rights (OCR), Region I received a complaint alleging that Veterans Health Administration, the covered entity, has violated the Federal Standards for Privacy of Individually Identi?able Health Information (45 CPR. Parts 160 and 164, Subparts A and E, the Privacy Rule). Speci?cally, the complaint alleges that the Veterans Health Administration impermissiny disclosed complainant?s protected health information to a congressman?s inquiry on the complainant?s behalf regarding a claim. This allegation could re?ect a violation of 45 C.F.R. ?164.502(a) 8.: OCR enforces the Privacy, Security, and Breach Noti?cation Rules, and also 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. In this matter, the complainant alleges that the covered entity does not employ reasonable safeguards to prevent impermissible disclosures of protected health information (PHI). A covered entity must maintain reasonable and appropriate administrative, technical, and physical safeguards to prevent intentional or unintentional use or disclosure of PHI in violation of the Privacy Rule and to limit its incidental use and disclosure pursuant to otherwise permitted or required use or disclosure. 45 C.F.R. Pursuant to its authority under 45 C.F.R. 160.3D4(a) and OCR has determined to resolve this matter informally through the provision of technical assistance to Veterans Health Administration. To that end, OCR has enclosed material explaining the Privacy Rule provisions related to Reasonable Safeguards. 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 any 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. In addition, OCR encourages you to review the facts of this individual?s complaint and provide the individual the appropriate written response swiftly if necessary to comply with the requirements of the Privacy Rule. Should OCR receive a similar allegation of noncompliance against Veterans Health Administration in the future, OCR may initiate a formal investigation of that matter. In addition, please note that, after a period of six months has passed, OCR may initiate and conduct a compliance review of Veterans Health Administration related to your compliance with the Privacy Rule?s provisions related to Reasonable Safeguards. 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 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 Phil Iewis, Investigator, at (617) 565-1355 (Voice) or (617) 565-1343 (TDD). Sincerely, Peter Chan Regional Manager Enclosure: Reasonable Safeguards