Part 2, Chapter 7: Manual Exhibit 2-7-G
Policy and Procedure for use and Disclosure for Directory Purposes
- PURPOSE. To publish Indian Health Service (IHS) policy and procedure for using and disclosing protected health information (PHI) for directory purposes.
- AUTHORITY. 45 Code of Federal Regulations 164.510(a)
- POLICY. An IHS facility may maintain a directory of inpatients and disclose limited PHI from that directory without the individual’s written authorization, provided the individual was informed of the intended use or disclosure in advance and had the opportunity to agree to or prohibit or restrict the use or disclosure.
The PHI that may be disclosed from a directory is limited to the individual's name, the individual's location in the facility, and the individual's condition (e.g., stable), described in general terms that do not communicate specific information. An individual's religious affiliation may be disclosed only to clergy, if the patient has not objected to such disclosure.
- PROCEDURES. The following procedures shall be used for using and disclosing information for directory purposes:
- Any restriction(s) on the use or disclosure of an individual's PHI will be noted on the form IHS 912-1, "Request for Restriction(s),” and such information will not be disclosed from the facility's directory of patients.
- If there are no stated restrictions to the release of an individual's PHI, the facility may disclose the individual's name, location within the facility, and condition in general terms upon request, by name of individual. Religious affiliation may also be disclosed to clergy who request such information, but clergy need not ask by patient's name.
- If the individual is incapacitated or in emergency treatment and does not have the opportunity to restrict or prohibit some or all of the uses or disclosures, the facility may disclose some or all of the directory information if such disclosure is consistent with any previously stated preferences. Any disclosure of directory information about an individual who has not had an opportunity to agree or object to the use or disclosure must be in the individual's best interest. The IHS facility must provide the individual with an opportunity to agree or object to any releases of his or her directory information as soon as the individual resumes making his or her health care decisions.
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