OFFICE or THE SECRETARY

DEPARTMENT OF HEALTH HUMAN SERVICES
- a
- 4041552-7335, [300}363101
i333 - i404) 552-?334. (soc) 53?-?697
(FAX) (404) saacsm
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11

Of?ce for Civil Rights, Region IV

6] Street, S.W. I
Atlanta Federal Center, Suite I6T70

Atlanta, GA 30303-3909

June 5, 2014

Ms. Andrea Wilson, RHIA, CIPP, CIPPXG

VHA Privacy Implementation Coordinator

Infonnation Access and Privacy Of?ce- 

Department of Veterans Affairs-Veterans Health Administration
310 Vennont Ave, NW

Washington, DC 20420

Re: OCR Reference Number: 12-142636
Dear Ms. Wilson:

 

 

 

 

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.

 

communication used. For example, when discussing patient health information orally with
another provider in proximity of others, a doctor may be able to reasonably safeguard the
information by lowering hisr'her voice.

In this matter, the complainant alleges the incidental use or disclosure of PHI was not
permissible, either because reasonable safeguards were not in place to prevent the use or
disclosure andfor because the minimum necessary standard was not implemented when it should
have been. 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 VI-IA. To that
end, OCR has enclosed material explaining the Privacy Rule provisions related to Incidental
Uses and Disclosures, Reasonable Safeguards, and the Minimum Necessary requirement.

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 VHA 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
infonnatiou 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.

I If you have any questions regarding this matter, please contact Sonya Hanafi, Investigator, at
(404) 562-7865 (Voice) or (404) 562?7884 (TDD).

 

Regional Manager
Office for Civil Rights

Enclosures: Incidental Disclosures
Reasonable Safeguards
Minimum Necessary