Part 2, Chapter 7: Manual Exhibit 2-7-H
Policy and Procedure for the use and Disclosure of
Protected Health Information During a Disaster and for
Disaster Relief Purposes
- PURPOSE. To publish Indian Health Service (IHS) policy and procedure on the use and disclosure of protected health information (PHI) during a disaster and for disaster relief purposes.
- AUTHORITY. 45 Code of Federal Regulations 164.510(b)(4)
- POLICY. The IHS may use or disclose PHI during a disaster and disaster relief to government agencies (Federal, State, local, or Tribal) engaged in disaster relief activities, as well as to private disaster relief or disaster assistance organizations (e.g., Red Cross and Salvation Army) authorized by law or by its charter to assist in disaster relief efforts, for the purposes of coordinating such efforts to allow them to carry out their responsibilities.
- DISASTER. For the purpose of this policy, a disaster is any event that overwhelms normal medical capability of the local facility and that triggers mass casualty medical readiness of the facility. A disaster may be declared by the facility leadership or by the Federal, State, local or Tribal government.
- PROCEDURES. The following procedures shall be used when using and disclosing PHI during a disaster and for disaster relief purposes.
- Notification. The IHS may use and disclose PHI for the purpose of notification (or assisting in the notification, identification, or location) of a family member, personal representative of the patient, or another person responsible for the care of the patient, of the patient's location, general condition, or death.
- Uses and Disclosures when Patient is Present. If the patient is present and/or available and can make health care decisions, the IHS will release the information if the IHS:
- obtains the patient's agreement;
- provides the patient the opportunity to object to the disclosure, and the patient does not express an objection; or
- reasonably infers from the circumstances, based upon the exercise of professional judgment that the patient does not object to the disclosure.
- Limited Uses and Disclosures when the Patient is not Present. When the patient is not present or when opportunity to agree or object is not possible or practicable due to the patient’s incapacity or emergency condition, an IHS provider, using his or her professional judgment, may determine that the use or disclosure is in the best interests of the patient, and only use or disclose PHI that is directly relevant to the government agency’s or disaster relief organization’s involvement with the patient’s health care.
- Compliance. The IHS must comply with the requirements of 5B and 5C, above, to the extent that it determines that the requirements do not interfere with the ability to respond to the emergency circumstance.
- Verification Procedure for Verification of Identity Prior to Disclosure of PHI. The verification procedure for verification of identity should be completed prior to disclosing PHI. (See Manual Exhibit 2-7-R, “Policy and Procedure for Verification of Identity Prior to Disclosures of Protected Health Information.”)
- Disclosures for Disaster Relief. Disclosures for disaster relief should be documented on the form IHS-505, “Disclosure Accounting Record or electronically in the Resource and Patient Management System Release of Information software application.” (See Manual Exhibit 2-7-B, “Policy and Procedure for Matters Related to Accounting of Disclosures of Protected Health Information.”)
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