Statement of Policy
Washington University and its member organizations (collectively, “Washington University” or “WU”) are committed to conducting business in compliance with all applicable laws, regulations and WU policies. As part of this commitment, WU has adopted a policy to define the circumstances under which Protected Health Information (PHI) may be Used or Disclosed with an Individual’s verbal agreement or when Authorization may be inferred from the circumstances.
Scope of Policy
This Policy applies to all Uses and Disclosures of PHI (i) to persons involved in an Individual’s Treatment and (ii) for purposes of notifying persons of an Individual’s location, general condition or death.
1) Disclosures to Persons Involved in the Individual’s Care or for Notification Purposes.
If the requirements of Paragraph 2 below are followed, WU may Use or Disclose PHI:
a) To a person involved in the Individual’s current Treatment (i.e., a family member or other relative, close personal friend, or other person identified by the Individual) ONLY to the extent that the PHI is directly relevant to such person’s involvement with the Individual’s care or Payment; or
b) To notify, or assist in the notification of, a family member, a personal representative of the Individual or another person responsible for the care of the Individual of the Individual’s location, general condition or death, and may include Disclosures to public or private entities authorized by law or charter to assist in disaster relief efforts.
2) Obtaining Verbal Authorization or Inferred Authorization
a) When the Individual is present and has capacity:
i) WU must inform the Individual verbally or in writing in advance of its proposed Disclosure of PHI to persons assisting in the Individual’s care (e.g., family members, close friends) and provide a meaningful opportunity for the Individual to orally agree, prohibit or restrict some or all of the Disclosure.
ii) PHI may be Disclosed if and only if:
• The Individual informs WU verbally or in writing that he or she approves of the proposed Disclosure.
• WU receives no objection from the Individual after giving the Individual a meaningful opportunity to object.
* W U reasonably infers that the Individual has no objection to the Disclosure.
iii) To the extent that the Individual objects in whole or in part to the proposed Disclosure, such Disclosure may not be made.
b) When the Individual is present and is mentally disabled:
If the Individual is unable to agree, object or restrict the Disclosure by reason of mental disability, the patient’s legal guardian may provide verbal authorization on behalf of the incapacitated Individual.
c) When the Individual is present and non-English speaking:
If the Individual is non-English speaking, the provisions of this Policy should be explained by an interpreter, if possible.
d) When the Individual is present and under the age of 18:
i) If the Individual is under the age of 18 and:
• is not pregnant
• does not already have children
• does not live apart from his/her parents and/or
• the Treatment at issue is not related to pregnancy, drug abuse, or venereal disease,
then the Individual’s parents (or other legal guardian or person standing in the place of the parents (i.e., grandparent or adult sibling)) may provide verbal Authorization to Disclose PHI on behalf of the minor Individual.
ii) If the Individual is under the age of 18 and:
• is pregnant
• has given birth to a child and is still the legal guardian to that child
• lives apart from his/her parents and/or
• the Treatment at issue is related to pregnancy, drug abuse, or venereal disease,
then the minor may provide verbal Authorization to Disclose PHI on behalf of him/herself.
e) When the Individual is not present or is incapacitated, or if there is an emergency circumstance:
i) WU may Disclose PHI to persons involved in the Individual’s current Treatment to the extent that WU determines, in the exercise of professional judgment, that the Disclosure is in the Individual’s best interest.
ii) In these circumstances, WU may Disclose only PHI that is directly relevant to the person’s involvement with the Individual’s Treatment.
(iii) WU should exercise professional judgment and apply its common practice experience to make reasonable inferences of the Individual’s best interest in allowing someone to act on behalf of the Individual. For example, pick up filled prescriptions, medical supplies, X-rays or similar forms of PHI.
(iv) This provision should be construed narrowly to allow Disclosures only to those persons who have the closest relationships with the Individual in circumstances in which the Individual cannot consent.
3) No Requirement to Verify Identity
WU is not required to verify the identity of persons to whom PHI is Disclosed pursuant to this Policy. For example, it is not necessary to verify that a person who claims to be the spouse of a patient (or parent, close friend, etc.) is, in fact, the spouse.
4) Deceased Patients
If an Individual is already deceased, WU should obtain verbal permission from the Individual’s next of kin before PHI is Disclosed. Missouri and Illinois law recognize the following order as “next of kin” and this order should be followed whenever possible. legally authorized representative.
ii) Adult son or daughter;
iii) Either parent;
iv) Adult brother or sister;
v) Any adult grandchild of the patient; or
vi) Any other person authorized to provide consent.
Creation Date: November 22, 2002
Effective Date: April 14, 2003
Last Revision Date: January 23, 2003