House Staff Manual - Winthrop University Hospital

to encourage and facilitate voluntary confidential HIV testing so that individuals can learn their HIVstatus and change behavior patterns that put them and others at risk;to limit the risk of discrimination and harm to an individual's interest and privacy; andto assure that confidential HIV related information is not improperly disclosed and to provide clearrules for the handling of such information, including permitted disclosures.DEFINITION OF CONFIDENTIAL HIV RELATED INFORMATION"Confidential HIV Related Information" is defined as any information, in the possession of a person whoprovides one or more health or social services or who obtains the information pursuant to a release ofconfidential HIV related information, concerning whether an individual has been the subject of an HIVrelated test, or has HIV infection, HIV related illness, or AIDS, or information that identifies or reasonablycould identify an individual as having one or more of such conditions, including information pertaining tosuch individual's contacts." Note: This includes cases where the only documentation may be a negativeHIV test result.CONFIDENTIALITY AND PERMITTED DISCLOSURESNo person who obtains HIV related information in the course of providing health or social services orpursuant to a special release may disclose that information except to a person or entity specificallyenumerated in the statute or unless the patient has signed a special release for the information.Included among those persons or entities to whom HIV information may be disclosed withoutproducing a special release are the following:Health care facilities and health care providers when necessary to provide appropriate care andtreatment of the individual;Agents or employees of health care providers or facilities who maintain or process medical records forbilling and reimbursement purposes;Third party payers to the extent necessary to reimburse health care providers for health care servicesdelivered; andQuality management committees or accreditation or oversight review organizations.The usual general release form used in releasing medical records information is not sufficient to permit thereleaser disclosure of HIV related information; only a special release that specifically permits the release ofHIV related information is sufficient.The Law specifically states that all HIV related information must be recorded in the patient's medicalrecord. In general, any disclosure made pursuant to the statute must be recorded in the medical record andmust be accompanied or followed by a statement prohibiting redisclosure. The statute provides fines forviolations (up to $5,000) of the Law and makes willful violations a misdemeanor.Disclosure of HIV related information without the signed consent of the patient (or authorized agent) by aWinthrop-University Hospital employee is permitted only when the release of information is necessary to:Provide appropriate care and treatment of the patient or to process medical information for billing, qualitymanagement of oversight activities.All other requests or subpoenas for patients' medical records, which contain HIV related information, are tobe directed to the Medical Records Department. This department will coordinate the release of all AIDSrelated information in accordance with the procedures set forth in the Law. Upon receipt of subpoenas andother court requests for HIV related information, Liability Control shall be contacted via the MedicalRecords Department.Rev. 1/08