yam? DEPARTMENT OF 3c HUMAN SERVICES OFFICE OF THE SECRETARY Voice - (214) ?6?-4056. (soc) ass-iota TDD . (214) tar-seam Of?ce for Civil Rights, Region VI '5 FAX - (214) ass-cor i gamma: not Young Street, Suite use Dallas,Tx 75202 . JUN 132012 i i {bli?lfbliilfcl Our Transaction Number: 1 1.13109? Deal- {bil?llbilil On July 28, 201], the U.S. Department of Health and Human Services (HHS), Of?ce for Civil Rights (OCR), Region VI received your complaint alleging that the Department of Veteran 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, on July 25, 2011, you received a phone call from a man identifying himself as li'i?l'iaimimic?J informed you that he received your military record and medical record in the mail from the epartrnent of Veteran Affairs. This allegation could re?ect a violation of 45 C.F.R. 164.502(a) and Thank you for bringing this niatter to attention. Your complaint plays an integral part in enforcement efforts. OCR enforces the Privacy, Siecurity, 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. The Privacy Rule permits ceriain incidental uses and disclosures of protected health information (PHI) that occur as a by-product of another permissible or required use or disclosure of PHI, as long as the covered entity has applied reasonable safeguards and implemented the minimum necessary standard, where applicable, with respect to the primary use or disclosure. See 45 CPR. For example, the Privacy Rule permits covered health care providers to share PHI for treatment purposes without patient authorization as long as they use reasonable safeguards when doing so; These safeguards may vary depending on the mode of communication used. For dxarnple, 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 his/liar voice. We have carefully reviewed your complaint against the Department of Veteran Affairs and have determined to resolve this matter informally through the provision of technical assistance to the Department of Veteran Affairs. Should OCR receive a similar allegation of noncompliance against the Department of Veteran Affairs in the future, OCR may initiate a formal investigation of that matter. i Based on the foregoing, is closing this case without further action, effective the date of this letter. determinatiorit as stated in this letter applies only to the allegations in this complaint that were reviewed'hy OCR. Under the Freedom of Infoniia?on 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 regalrding this matter, please contact Vaniecy Nwigwe, Investigator, at 214-767-4054 (Voice), 2144673940 (TDD). Sincerely, 54', Ralph D. Rouse Regional Manager Region VI Regional Manager with qt if an DEPARTMENT OF 3: HUMAN SERWCES OFFICE OF THE SECRETARY voice - (214) rot-toss, (soc) 363-1le TDD - {214) rot?394:} Of?ce for Civil Rights, Region VI Jpql'il?. FAX - (214) totem . WW 1301 Young Street, Suite use i Dallas, Tx 752s: JUN 18 2012 Ms. Andrea Wilson, RHIA, CIPPIG VHA Privacy ImplementationiCoordinator Information Access and Privady Of?ce-1 0P2C1 Department of Veteran Affairsi-Veteran Health Admin. 810 Vermont Avenue, N.W. 3 Washington, DC. 20420 Our Transaction Number: 11-l131097 Dear Ms. Wilson: i On July 23, 201 1, the U.S. Diepartment of-Health and Human Services (HHS), Of?ce for Civil Rights (OCR), Region VI received a complaint alleging that the Department of Veteran 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, the complaint alleges that. the Department of Veteran Affairs mailed the military record and medical record I to Itblt?libltl'ltcl I This allegation could re?ect a violation of 45 has, 164.502(a) and 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. The Privacy Rule permits certain incidental uses and disclosures of protected health information (PHI) that occur as a lay-product of another permissible or required use or disclosure of PHI, as long as the covered entity applied reasonable safeguards and implemented the minimum necessary standard, where applicable, with respect to the primary use or disclosure. See 45 CPR. example, the Privacy Rule permits covered health care providers to share PHI for treatment purposes without patient authorization as long as they use reasonable safeguards when doing soi These safeguards may vary depending on the mode of 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 hisflier 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 the Department of Veteran Affairs. 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 revievir 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 asQalleged 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 the Department of Veteran Affairs 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. determinatiori 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 upbn 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 identifies individuals or that, if released, could constitute a clearly unwarranted invasion of personal privacy. If you have any questions regarding this matter, please contact Vaniecy Nwigwe, Investigator, at 214-767?4054 (Voice), meter-3940 (TDD). Sincerely, . Ralph D. Rouse i Regional Manager Region VI Regional Manager Enclosures: Incidental Disclosures Reasonable Safeguards Minimum Necessary