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When is a privacy acknowledgement valid?

Compliance Monitor, September 9, 2005

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Q: How long is a privacy acknowledgement valid? If the patient is admitted into a facility within the organization, can facilities share this information, and if so, for how long? Do we need a new acknowledgement for each episode, or within a certain time? My thought was that the patient only had to sign once, but I am hearing that many hospitals are having the patient sign during each admission. Thanks for any help you can give us on this question.

A:HIPAA privacy regulations require covered entities (e.g. hospitals and physicians) with a direct treatment relationship with patients to provide patients with a notice of privacy practices. The rule requires facilities to provide this notice at the patient's first service encounter and to make a good faith effort to obtain the patient's written acknowledgment of receipt of the notice.

If the provider maintains an office or other physical site for providing healthcare directly to individuals, the provider must also post this notice in that facility in a clear and prominent location, as well as provide it to those who request a copy. In emergency treatment situations, the provider must furnish its notice as soon as practical after the emergency.

Based on the regulations, providers need only provide the notice of privacy practices (NPP) once-at the time of first service delivery. The privacy acknowledgements do not expire; they are good "forever."

Moreover, if a covered entity changes its NPP, the privacy rule does not require the provider to mail out its revised notice or otherwise notify patients by mail. Rather, the provider must provide the notice to patients upon request, and post the revised NPP at the physical service delivery site, as well as post the notice on its customer-service web site, if the provider has one.

This week's answer was provided by Norman S. Werner, CHE, corporate director of Corporate Compliance at Continuum Health Partners, Inc. in NY. Werner is a diplomate in the American College of Healthcare Executives.

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