Page 62 - Privacy_Program

CONDITIONING SERVICES ON THE PROVISION OF AN AUTHORIZATION TO DISCLOSE PHI [DP131]
Back to Table of Contents

Scope: Enterprise
Distribution: Executive Leadership Team; Director of Information Technology, Privacy and Data Security; Services and Programs
Directors, Managers and Supervisors; Employees and Others with Access to Protected Health Information
Purpose: To demonstrate the organization’s commitment to providing services even if no authorization to disclose protected health
information is obtained. “Conditioning services on obtaining an authorization” is defined as requiring the participant to sign an
authorization allowing for the disclosure of certain protected health information in order to provide services.
External Regulation or Standard: 45 C.F.R. § 164.508 ‐ Prohibition on conditioning of authorizations

Who is Responsible Statement Policy, Standard, or Procedure Statement
Number
Employees and DP131.1 The organization may, if deemed necessary within professional judgment,
others with Access condition the following on obtaining an authorization:
to PHI
DP131.1a (a) providing research‐related treatment;

DP131.1b (b) providing health care that is solely for the purpose of creating Protected
Health information for disclosure to a third party; and
DP131.1c (c) enrollment in benefits or services if the authorization is requested prior to
enrollment.
Employees and others DP131.2 Except as provided above, the organization will not condition an individual’s
with Access to PHI treatment or payment for services on the provision of an authorization to use or
disclose PHI.

Employees and others DP131.3 All requests for disclosures of PHI that require authorization will be directed to
with Access to PHI professional staff serving the participant.
Chief Services and DP131.4 Professional staff serving the participant will discuss the request with the
Programs Officer, S&P Chief Services and Programs Officer or Chief‐assigned Director, and Director
Directors and Director of Information Technology, Privacy and Data Security. The Chief Services
of Information and Programs Officer or Chief‐assigned Director will determine the nature
Technology, Privacy of the request and decide whether it is necessary to condition payment or
and Data Security services on obtaining the authorization. This policy describes the deciding
factors.
Employees and DP131.5 If such conditions are determined necessary, professional staff serving the
others with Access individual will inform the participant, potential participant, or applicable provider,
to PHI including the reason for the conditioning of services.

Employees and DP131.6 All authorization forms for the use or disclosure of PHI will include a statement
others with Access that the individual’s treatment and payment for services will not be conditioned
to PHI on provision of the authorization, except as permitted by law.
Employees and others DP131.7 When the organization is permitted to condition an individual’s treatment on
with Access to PHI provision of an authorization under this policy, the authorization form will state
the consequences to the individual of refusing to sign the authorization.

GES CONFIDENTIAL 58