Page 75 - Privacy_Program

DISCLOSING PHI FOR PUBLIC HEALTH AND SAFETY [DP165]
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Scope: Enterprise
Distribution: Executive Leadership Team; Director of Information Technology, Privacy and Data Security; All Employees
with Access to Protected Health Information (includes Contractors, temporary employees and Interns)
Purpose: To clarify when the organization can disclose Protected Health Information for public health and safety purposes.
External Regulation or Standard: 45 C.F.R. §164.512(j) ‐ uses and disclosures to avert a serious threat to health or safety; 45
C.F.R.
§164.512(b) ‐ uses and disclosures for public health activities; 45 C.F.R. §164.512(d) ‐ uses and disclosures for health
oversight activities

Who is Statement Policy, Standard, or Procedure Statement
Responsible Number
Employees and DP165.1 The organization, consistent with all applicable laws, may use or disclose
Others with Access Protected Health Information (PHI), if the organization, in good faith, believes
to Protected Health the use or disclosure is necessary to prevent or lessen a serious and imminent
Information (PHI), threat to the health or safety of a person or the public.
with Chief or
assigned Director or
Manager
Employees and others DP165.2 The organization may make disclosures of PHI to persons or entities that are
with Access to PHI, with reasonably able to prevent or lessen the threat, including to the target of the
Chief or assigned threat. Further, the organization will make such disclosures only when the belief
Director or Manager is based upon the organization’ actual knowledge, or in reliance on a credible
representation by a person with apparent knowledge or authority.

Employees and Others DP165.3 Consistent with applicable law, standards of ethical conduct, and this policy, the
with Access to PHI, with organization may use or disclose PHI under the following circumstances:
Chief or assigned
Director or Manager
DP165.3a (a) to prevent or lessen a serious and imminent threat to the health or safety of
a person or the public;
DP165.3b (b) for law enforcement authorities to identify or apprehend an individual
because of a statement by an individual admitting participation in a violent crime
that the organization reasonably believes may have caused serious physical harm
to the victim;
DP165.3c (c) for law enforcement authorities to identify or apprehend an individual where
it appears from all the circumstances that the individual has escaped from a
correctional institution or from lawful custody;
DP165.3d (d) to identify or apprehend an individual made pursuant to a statement by the
individual admitting participation in a violent crime that the organization
reasonably believes may have caused serious physical harm to the victim. The
disclosure shall contain only that specific statement, and shall contain only the
following privacy restricted information:
DP165.3d.i • name and address;
DP165.3d.ii • date and place of birth;
DP165.3d.iii • social security number;
DP165.3d.iv • ABO blood type and rh factor;
DP165.3d.v • type of injury;
DP165.3d.vi • date and time of treatment;

GES CONFIDENTIAL 71