5.00 - USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION FOR TREATMENT, PAYMENT OR HEALTH CARE OPERATIONS PURPOSES

I. Purpose:
To issue instructions to ADAMH workforce members regarding the use and disclosure of protected health information (PHI) and necessary documentation of authority for such use or disclosure, for purposes of treatment, payment and health care operations (TPO).

II. Applicability:
This policy applies to all ADAMH workforce members

III. Authority:
45 CFR Parts 160 & 164

IV. Definitions:

Business Associate (BA) means a person or entity who, on behalf of ADAMH, but not in the capacity of a workforce member; performs or assists in the performance of a function or activity that involves the use or disclosure of protected health information (PHI); or provides legal, actuarial, accounting, consulting, data aggregation, management, administrative, accreditation, or financial services.

Protected Health Information (PHI) means individually identifiable information relating to the past, present or future physical or mental health or condition of an individual, provision of health care to an individual, or the past, present or future payment for health care provided to an individual.

Disclosure means the release, transfer, provision of access to, or divulging in any other manner of information outside the entity holding the information.

Use means with respect to individually identifiable health information, the sharing, employment, application, utilization, examination, or analysis of such information within an entity that maintains such information.

Treatment, Payment and Health Care Operations (TPO) includes all of the following:

Treatment means the provision, coordination, or management of health care and related services, consultation between providers relating to an individual, or referral of an individual to another provider for health care.
Payment means activities undertaken to obtain or provide reimbursement for health care, including determinations of eligibility or coverage, billing, collection activities, medical necessity determinations and utilization review.
Health Care Operations include functions such as quality assessment and improvement activities, reviewing competence or qualifications of health care professionals, conducting or arranging for medical review, legal services, and auditing functions, business planning and development, and general business and administrative activities.

Personal Representative means a person who has authority under applicable law to make decisions related to health care on behalf of an adult or an emancipated minor, or the parent, guardian, or other person acting in loco parentis who is authorized under law to make health care decisions on behalf of an unemancipated minor, except where the minor is authorized by law to consent, on his/her own or via court approval, to a health care service, or where the parent, guardian or person acting in loco parentis has assented to an agreement of confidentiality between the provider and the minor.

Workforce Members means Board of Trustees members, employees, volunteers, trainees, and other persons whose conduct, in the performance of work for ADAMH, is under the direct control of ADAMH, regardless of whether they are paid by ADAMH.

V. Policy:

1. Generally: In compliance with 45 CFR Part 164 and Ohio law, an individual's authorization (or authorization from a personal representative) must be obtained prior to using or disclosing protected health information to carry out treatment, payment or health care operations, except as specified below.
2. Exceptions:
   1. PHI may be shared on a need to know basis with personnel within ADAMH and/or with business associates, for activities related to treatment, payment, or health care operations.
   2. Limited PHI [medication history, physical health status and history, summary of course of treatment, summary of treatment needs, and discharge summary] may be used or disclosed for TPO without authorization if disclosure is to another program of the ADAMH Board, or to community mental health agencies with which there is a current agreement for the individual's care or services, and an attempt has been made to obtain the individual's consent to the disclosure.
   3. Limited PHI [medication information, summary of diagnosis and prognosis, list of services and personnel available for assistance] may be disclosed to family members, other relatives or friends involved in the individual's care, or payment for that care, if the individual is notified and does not object to the disclosure.
   4. In emergency treatment situations, necessary information for treatment may be disclosed if an attempt is made to obtain consent to the disclosure as soon as reasonably practicable after the delivery of treatment.