Page 37 - Privacy_Program

PERSONAL REPRESENTATIVES [DP134]
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Scope: Enterprise
Distribution: Executive Leadership Team; Director of Information Technology, Privacy and Data Security; Directors, Managers and
Supervisors; Services and Programs Employees; and Other Employees with Access to Protected Health Information and Other Privacy‐
Restricted Participant Information Purpose: To clarify when the organization must treat a personal representative of a participant as
the participant for privacy purposes.
External Regulation or Standard: 45 C.F.R. §164.502(g) ‐ Standard: personal representative

Who is Responsible Statement Policy, Standard, or Procedure Statement
Number
Employees with Access DP134.1 The organization will treat a person as a personal representative of a participant
to Protected Health with respect to disclosure of PHI or other PRPI if under applicable law:
Information (PHI) and
Other Privacy‐
Restricted Participant
Information (PRPI)
DP134.1a (a) a parent, guardian, or other person acting in loco parentis (in the place of a
parent) has authority to act on behalf of a participant who is an unemancipated
minor in making decisions related to health care; or

DP134.1b (b) an executor, administrator, or other person has authority to act on behalf of
a deceased participant or of the participant’s estate.

Employees and others DP134.2 The organization will treat a person as a personal representative of a deceased
with Access to PHI and participant with respect to the PHI or other PRPI if under applicable law the
Other PRPI person is an executor, administrator, or other person with authority to act on
behalf of the deceased individual or of the individual’s estate.

Employees and others DP134.3 In the following circumstances, the organization will not treat a person as a
with Access to PHI and personal representative of an unemancipated minor; when the minor has
Other PRPI authority to make decisions about their PHI or other PRPI pertaining to a health
care service if:

DP134.3a (a) the minor consents to such health care service, no other consent is required
by applicable law, and the minor has not requested that another person be
treated as the personal representative;

DP134.3b (b) applicable law permits the minor to obtain such health care service without
the consent of a parent, guardian, or other person acting in loco parentis; and
the minor, a court, or another person authorized by law consents to such
health care service; or

DP134.3c (c) a parent, guardian, or other person acting in loco parentis assents to an
agreement of confidentiality between a covered health care provider and the
minor with respect to such health care service.

Employees and others DP134.4 The organization will not treat a person as the personal representative of a
with Access to PHI and participant if:
Other PRPI
DP134.4a (a) The organization believes or has reason to believe that the participant has
been or may be subjected to domestic violence, abuse, or neglect by such

GES CONFIDENTIAL 31