Health Information Management

What should a notice of privacy practices include?

HIPAA Weekly Advisor, September 17, 2001

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Q: What should a notice of privacy practices include?

A: Under HIPAA's Privacy Rules, covered entities are required to provide adequate notice of their privacy practices to affected individuals in the following instances:

Providers: when first giving service to a new patient

Health plans: when the privacy rule goes in effect to all subscribers, and subsequently when new subscribers enroll

Clearinghouses: when creating or receiving protected health information in a capacity other than that of a business associate

An adequate privacy notice must include all of the following:

  • The required heading
  • A statement of uses and disclosures
  • A statement of individual rights
  • A statement of the covered entity's duties
  • An explanation of how to complain
  • Required contract information
  • Optional information if desired

The notice rule is rather long and complex. Before drafting a privacy notice, it is essential to read this section of the rule and the preamble. Here are some key points to keep in mind when you write your HIPAA privacy notice:

1. The notice must be "adequate."
Your notice will only be adequate if it meets all of the requirements of the rule, not just some of them. The rule is a set of minimums, not best practices.

2. You may need to draft more than one notice.
Covered entities that do business in multiple states must write a notice for each state because most states have different laws, and if those laws are more stringent than HIPAA, they must be followed.

Also, providers may need separate notices for separate lines of business. For example, an OB/GYN group may provide on-call coverage as part of an arrangement with a hospital and also run a private group practice. Here, the group might distribute one notice developed by the hospital and another notice for the private group.

For more tips on drafting a notice of privacy practices, see the September 2001 issue of Briefings on HIPAA.

Answered by Edward F. Shay, a partner in the national health law practice at the Philadelphia-based law firm of Post & Schell, P.C. Mr. Shay may be reached at eshay@postschell.com.



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