UTMB HANDBOOK OF OPERATING PROCEDURES

Section 6 Compliance Policies Subject 6.2 Privacy Related Policy 6.2.6 Confidentiality of Substance Abuse Treatment Program Records

04/11/03 - Originated 10/08/07 - Reviewed w changes - Reviewed w/o changes Compliance Office - Author

Confidentiality of Substance Abuse Treatment Program Records

Definition

Substance Abuse Treatment Program Record: Records of the identity, diagnosis, prognosis, or treatment of any patient which are maintained in connection with the performance of any program or activity relating to substance abuse education, prevention, training, treatment, rehabilitation, or research, which is conducted, regulated, or directly or indirectly assisted by UTMB. The Substance Abuse Treatment Record does not apply to screening unless the screening is part of the treatment process.

Policy

UTMB, in an effort to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), maintains that patient information must be kept private and confidential. Substance Abuse Treatment Records are considered a unique subset of PHI, which must be treated differently from other types of PHI. UTMB must ensure that Substance Abuse Treatment Records will be confidential and will be disclosed only for the purposes expressly authorized by the patient, except as provided in the Permitted Disclosures section of this policy. An authorization to release Substance Abuse Treatment Records must be obtained for any use and disclosure not related to Treatment, Payment, or Healthcare Operations (TPO) Substance Abuse Treatment Records may be released if the individual has provided an authorization as required in IHOP Policy 6.2.1,, Uses and Disclosures of PHI Based on Patient Authorization. Violation of this policy may result in disciplinary action up to and including termination for employees; a termination of employment relationship in the case of contractors or consultants; or suspension or expulsion in the case of a student. Additionally, individuals may be subject to loss of access privileges and civil and/or criminal prosecution.

Permitted Disclosures

The content of any Substance Abuse Treatment Record may be used and disclosed in accordance with the prior written consent of the patient for TPO. For any other use or disclosure of a Substance Abuse Treatment Record, UTMB or the Substance Abuse Treatment Director or designee must have an authorization from the individual granting UTMB permission to disclose the information prior to the release of any portion of a substance abuse treatment record. However, UTMB may disclose the Substance Abuse Treatment Record without the patient’s authorization if: 1. Medical personnel are required to treat the individual in an emergency situation; 2. Qualified personnel are conducting management audits, financial audits, or program evaluation, so long as such personnel do not identify, directly or indirectly, any individual patient in any report of such research, audit, or evaluation, or otherwise disclose patient identities in any manner; 3. An individual is authorized to disclose by an appropriate order of a court of competent jurisdiction; or 4. UTMB is required by law to report information in the Substance Abuse Treatment Records. Accounting of Disclosures: Certain disclosures of PHI outside of UTMB require documentation. See IHOP Policy 6.2.28, Accounting of Disclosures of PHI. Use of Records in Criminal Proceedings: Except as authorized by a court order, no Substance Abuse Treatment Record may be used to initiate or substantiate any criminal charges against a patient or to conduct any investigation of a patient. Application: The prohibitions of this policy continue to apply to records concerning any individual who has been a patient, even when such individual ceases to be a patient.

References

42 C.F.R. part 2