Privacy Patient Right to Object to Disclosures (“Opt Out”)

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Introduction Patients of UNC Health Care have the right to object to certain uses and disclosures of their Protected Health Information (PHI). This module will explain the process for responding to a patient’s request to object to disclosures (or “opt out”).

General Consent for Treatment UNC Health Care will obtain a General Consent for Treatment from all patients which also includes: • consent to use or share PHI for Treatment, Payment, Healthcare Operations (TPO) • acknowledgement of receipt of Notice of Privacy Practices (NPP) • opportunity to prohibit or restrict the use or sharing of PHI also known as “Opt Out” • financial information

Notice of Privacy Practices (NPP) The NPP is a summary of the privacy policies and procedures of UNC Health Care which informs patients of their rights and UNC Health Care’s requirements for the privacy of PHI.

Notice of Privacy Practices (NPP) • The NPP must be given to each patient on his/her first visit to UNC Health Care. Patients may request an additional copy of the NPP at any time. • The NPP must be posted and copies made available (in both English and Spanish) in all patient registration and/or check-in areas. • A patient must acknowledge his/her receipt of the NPP in writing.

For Example: Mr. Presley comes to a clinic and he is provided a packet of information which includes the NPP. He is asked to read and sign the General Consent for Treatment form. He returns the form to Sandra, a Clinical Business Associate, who reviews it to verify the information is complete. Pointing to the NPP acknowledgement area of the form, she asks him, “Mr. Presley, would you also please sign here saying that you have read the NPP?” Is Sandra’s request appropriate?

For Example: No. Signing the acknowledgement only states that the patient has RECEIVED the NPP, not read or understood it. Sandra should only ask Mr. Presley to acknowledge that he was given an NPP with his check-in packet.

Patient Right to Object to Disclosures: Patient List / Census List UNC Health Care maintains a list of patients currently in the hospital. This allows us to provide the following information to those who ask for the patient by name. Unless the patient opts out, we can provide: • The patient’s location • The patient’s general condition “stable”, “serious”, or “critical”

Patient Right to Object to Disclosures: Patient List / Census List Unless the patient opts out, the patient’s location and religious affiliation are included in a clergy list shared with community clergy (not employed by UNC Health Care) upon request. UNC Health Care Pastoral Care staff will also have access to this information.

Patient Right to Object to Disclosures: Patient List / Census List • Patients may opt out at the time of admission and at any time while at UNC Health Care. • The patient will note these objections in the space provided on the General Consent for Treatment form. • This form is filed in the medical record and opt outs are entered in the registration system. • With very few exceptions, staff may not opt out for the patient. Exceptions require the approval of your Privacy Officer. • All patients admitted to a Psychiatry service are automatically opted out.

Patient Right to Object to Disclosures: Patient List / Census List If the patient decides to alter these objections, he/she will complete a new General Consent for Treatment form which will be filed in the medical record and the revisions entered in the registration system.

Patient Right to Object to Disclosures: Patient List / Census List If a patient “opts out” of the patient list: • his/her information will not be shared with outside callers or visitors • the patient is not included in the patient list maintained by the Hospital telephone operators. • all patient names, including those patients who have “opted out”, appear on all other internal patient lists with the appropriate “opt out” flags. Please refer to the UNC Health Care Privacy/Security Reference Sheet on the UNC Health Care HIPAA web site for additional information regarding the “opt out” flags.

Patient Right to Object to Disclosures: Patient List / Census List • If a patient “opts out” of the patient list, callers or visitors should be told, “I have no information available on that person.” • If a caller or visitor continues to ask about a patient who has “opted out”, the staff should suggest that the caller or visitor contact the person’s family or their source of information.

Patient Right to Object to Disclosures: Patient List / Census List If the caller or visitor is still not satisfied, the staff should contact their department manager/director for assistance. The department manager/director may choose to contact the patient to alert them to the situation.

Patient Right to Object to Disclosures:Sharing Information with Family and/or Friends Unless the patient objects, limited PHI may be shared with family, friends and/or representatives of the patient: • when sharing the information relates to his/her care or payment for care, or • when needed to notify individuals about the patient’s location or general condition.

For Example: When Mrs. Jackson is admitted, she signs a General Consent for Treatment Form and does not choose to “opt out” of any areas. She calls her nurse into her room very upset because she just received a phone call from someone she did not want to know she was in the hospital. The patient says they received information from the front desk. Should this person’s information have been disclosed? Could anything have been done differently?

For Example: Because Mrs. Jackson did not choose to “opt out” of the patient directory, callers inquiring about her by name would receive confirmation of her admission and general information about her condition. The only thing that might have been done differently is a better explanation upon check-in of these opt outs so that the patients may make the appropriate choices to suit their desires.

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Privacy Patient Right to Object to Disclosures (“Opt Out”)