Health Information Management

HIPAA Q&A: You’ve got questions. We’ve got answers!

HIM-HIPAA Insider, October 20, 2014

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Submit your HIPAA questions to Editor Jaclyn Fitzgerald at and we will work with our experts to provide you with the information you need.

Q: The state department of health usually requests ED log books to determine the number of patients treated for certain health issues at the facility where I work. Is the department of health authorized to request these log books to gather information for data collection? Although HIPAA states that anyone a covered entity (CE) shares PHI with is a business associate (BA), one of my colleagues told me that our organization does not need a BA agreement to exchange PHI with government entities. How does HIPAA apply in this situation?
A: CEs can share certain information with the government for purposes defined in the HIPAA Privacy Rule. For example, PHI may be shared for the purpose of a Medicaid or Medicare audit, for public health purposes, to report abuse, and so forth. In these cases, the government is not a BA and is entitled to the information.
The state department of health is likely not entitled to view the full ED log. If the department is interested in, say HIV/AIDS admits or admits for communicable diseases, it would be entitled to that information, but not to information about all patients who are treated in the ED.
A word of caution, though. Unless allowed, such as when OCR decides to audit, you need to adhere to the minimum necessary standard even when disclosing patient information to government agencies. Also, it's a good idea to ensure the government agency requesting information is authorized to access the PHI. For example, if a request is received to disclose PHI to law enforcement, only the minimum necessary can be disclosed, and if possible, only a limited data set can be disclosed. It's always a good idea to authenticate the requestor before disclosing PHI and document you authenticated who you were sharing PHI with.
Editor’s note: Chris Apgar, CISSP, president of Apgar & Associates, LLC, in Portland, Oregon, answered this question for HCPro’s Briefings on HIPAA newsletter.



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