Health Information Management

Privacy notices for testing without an office visit

HIPAA Weekly Advisor, May 15, 2003

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Q: We are a cardiology practice that has several stand-alone testing facilities. Is it necessary to hand patients the privacy notice and have them sign an acknowledgement of receipt when they have testing that requires no office visit?

A: First, whether patients make one visit or several has no bearing on whether they must sign an acknowledgement of receipt. What matters here is whether the provider-the testing facility-is a direct or an indirect treatment provider. While all health plans, providers, and some others are required to develop and make available a HIPAA-compliant privacy notice, only direct treatment providers are required to actively hand it out and obtain a one-time acknowledgement of receipt. Often, lab and testing facilities are defined as indirect treatment providers under HIPAA, so this is not required.

The notice of privacy practices, how it should be handled, who needs to get acknowledgements, and how to handle them still appears to cause confusion among covered entities. Here are a few reminders:

  • You only need to hand out the privacy notice once to any given patient. If you change the notice, you need to prominently post the change. But you are not required to hand out new copies and obtain another acknowledgement of receipt.

  • When a direct treatment provider attempts to get an acknowledgement, some patients may not understand that they are only being asked to indicate they have received the notice. They sometimes balk (for example, "I want to take it home and have my son read it first"). If this happens in your organization, and the patient refuses to sign or initial your acknowledgement even after it has been explained, then you have satisfied the privacy rule requirement. Just be sure that your staff documents that the attempt was made. And be sure staff members understand that they do not need to continue to seek acknowledgement during future visits.

  • Some organizations are asking patients to sign or initial on a copy of the privacy notice itself. While this is perfectly acceptable, it may not be practical and it may be confusing. You must give the notice to the patient to keep. For your records, all you need is a piece of paper, not the full notice. The paper should contain a simple statement such as, "I have received ABC Hospital's notice of privacy practices." Have the patient sign or initial the document. Then date and file it.

  • Also note that you must have available copies of your notice to give anyone who asks. One pharmacy chain prints its privacy notice on the back of its prescription information. That is nice for someone picking up a prescription, but the pharmacy should also have copies it can give to anyone who asks.

    Editor's note: Answered by Kate Borten, CISSP, president of The Marblehead Group, in Marblehead, MA, and excerpted from the upcoming June 2003 issue of Briefings on HIPAA. This is not legal advice. Be sure to consult with your facility's legal counsel for legal matters.



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