DEPARTMENT OF HEALTH 8; HUMAN SERVICES 0?5? 0" the swam? Voice - (4:34} 562-7336. (son) 368-1019 TDD (404) 562-7334. (soc) 537-7697 Of?ce for Civil Rights, Region IV Atlanta Federal Center. Suite Fax - (404) 562-71381 hm'Mhhagovfocr 61 Street. SW. Atlanta, GA 30303 September 20, 2013 Privacy Of?cer CVS Pharmacy One CVS Drive Woonsocket, RI 02395 RE: lv. CV3 Pharman Reference No: 12-]45065 Dear Privacy Of?cer: On August 9, 2012, the Department of Health and Human Services (HHS), Of?ce for Civil Rights (OCR) received a complaint from alleging non-compliance with the Federal Standards for Privacy of Individually Identi?able Health Information andfor the Security Standards for the Protection of Electronic Protected Health Information (45 CPR. Parts 160 and 164, Subparts A, C, and E, the ?Privacy and Security Rules?) and the Breach Noti?cation Rule Subpart - Noti?cation in Case of Breach of Unsecured Protected Health Information 4S C.F.R. - [alleged that her PHI was provided by Himmlle to an acquaintance of hers not authorized by her or the Privacy Rule to have received this PHI. This allegation could re?ect a violation of 45 C.F.R. 164.510 and 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 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 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 21111 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 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 with such policies and procedures or with the requirements of the Privacy Rule. 45 CPR. 164.530 In this matter, the complainant alleges that the complainant?s PHI was impermissiny 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 CPR. 160.304(a) 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 ?iture, 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 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 bylaw, 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 E. Schwalb at (404) 562-2790 (Voice) or (404) 562-7384 (TDD). Sincerely, ?an/K 53- M?w Frank Campbell Acting Regional Manager it) .e i NW. DEPARTMENT OF HEALTH HUMAN SERVICES 0m 0? the Secretary Voice - (404} 562-7886. (300) 363-1019 TDD - [404) 562-?334, {300} Fax - (404) 5623881 vaMhhegovfocr Of?ce for Civil Rights, Region IV Atlanta Federal Center, Suite 16170 61 Street. SW. Atlanta, GA 30303 September 20, 2013 (bli?llbliillCl RE: ?humming lv. CVS Pharmacy Reference No: lit?145065 . as Dear-i l( l{ it Hi On August 9, 2012, the US. Department of Health and Human Services (HHS), Of?ce for Civil Rights (OCR), Regioan received your complaint alleging that CVS Pharmacy, the covered entity, has violated the Federal Standards for Privacy of Individually Identi?able Health Information (45 .F.R. Parts 160 and 164, Subparts A and E, the PrivaCy Rule) and the Breach Noti?cation Rule Subpart - Noti?cation in Case of Breach of Unsecured Protected Health Information (45 C.F.R. You alleged that your PHI was disclosed by a CVS employee to an acquaintance of yours who you never authorized to receive such PHI. This allegation could re?ect a violation of 4S C.F.R. 164.510 and Thank you for bringing this matter to attention. Your complaint plays an integral part in 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 identi?ed 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 obj ect. 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 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 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 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 ?iture, 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 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 E. Schwalb at (404) 562-2790 (Voice) or (404) 562-?884 (TDD). Sincerely, M2 zed/M %m Frank Campbell fActing Regional Manager