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It is the policy of the center to maintain an individual’s right to privacy and confidentiality of information. Information known or contained in the patient’s medical record (known as protected health information) shall be treated as confidential and will be released in appropriate circumstances only with the written consent of the patient or legal guardian. Information concerning patients, visitors, and staff shall be managed with the highest degree of appropriateness and confidentiality, pursuant to organization wide policies and procedures.




  • All persons employed at the center having access to information concerning patients, such as facility staff members and physicians must hold all information in strict confidence, and shall abide by the Health Insurance Profitability and Accountability Act (HIPAA) regulations.

  • Information concerning patients which may be considered ordinary facts and necessary for planning of specific care and services, will be handled with professional discretion and on a “need to know” basis.

  • Information regarding physicians, staff members or volunteers is to be relayed to others as appropriate to the related job function or task and/or to facilitate patient care and services only. Information regarding physicians, staff members or volunteers is to be kept on a professional level, and only discussed in relationship to the individual’s purpose and function within the institution.

  • Requests for patient information will be directed to the Medical Record Department. Disposition of such requests will be in accordance with the facility’s established policy and procedure for Release of Information and pursuant to the HIPAA regulations.

  • Advances in technology will be reviewed as these are made available to the institution, to ensure that the technology maintains and protects privacy and confidentiality of personal health information.

  • Personal opinions as to the competence of facility staff members or any staff members, are not to be expressed in a public environment and should always be addressed to the staff members supervisor, facility administrator, Clinical Manager, or the Medical Director for resolution.

  • At no time shall physicians, staff members, or others associated with the center engage in discussions of a personal nature which are unrelated to the organization’s mission, values and purpose (i.e., gossip).

  • At no time shall staff members, or others associated with the center, who have access to confidential patient information. Speak with the news media, or others outside the facility, without prior approval from facility administration. All encounters with the news media should be directed to administration.

  • All staff will be educated and trained about the requirements for information privacy and confidentiality appropriate for each level of employee to carry out his/her healthcare function within the facility. Education and training includes, orientation, initial education and any ongoing education and training necessary related to changes with this organization’s information confidentiality and privacy practices.

  • Enforcement of the principles of this policy will be monitored through the combined efforts of the Associate Administrator, Clinical Manager, and Medical Director. Monitoring of violations of this policy will be conducted with reports submitted to the President.

  • Outcomes from monitoring activities will be analyzed to determine if improvements can be made in privacy and confidentiality practices.




  • Information (both written and verbal) concerning patients, practitioners, contractors, and other business concerns is considered confidential and will not be disclosed to anyone other than properly authorized persons or as otherwise requested by state or federal regulations.

  • All employees are required to sign a Confidentiality Agreement upon hire.

  • Minutes of medical staff committees shall refer to practitioners and patients by identification numbers only.

  • Computer files will be given all protection available and backup files will be kept in a secured location

  • Also refer to organizational HIPAA policies and procedures.




To assure that the patient’s rights of privacy are maintained.




It is the policy of the center to protect all patient’s rights of privacy. However, it is recognized that the right of privacy is not absolute and must be weighed and balanced against competing situations.




  • Consent must be obtained from the patient to release information to third parties. When referring to release of written information, personnel are to contact the Medical Record Department and refer the requesting individual to that department

  • When receiving inquiries regarding a patients condition by family members, friends and visitors, the following must be observed:

    • The individual requesting information must provide evidence of his/her identity, upon which time if the patient is able to consent, verbal consent will be obtained from the patient and documented in the medical record.

      • The information verbally provided by personnel will consist of only brief description on the patient’s current condition in terms of “stable”, “improving”, etc. the clinical healthcare provider must use their judgement in providing additional information and prudence is required.

    • If the patient is unable to provide verbal consent due to physical or mental incapacitation and there is an assigned surrogate decision maker for the patient, consent for release of verbal information will be obtained from the surrogate and documented in the medical record.

    • If the patient is unable to provide verbal consent due to physical or mental incapacitation and there is no assigned surrogate decision maker, verbal information, as outlined in this policy, may be provided to the following individuals:

      • Husband/wife

      • Adult children

      • Children (as appropriate to age)

      • Siblings

      • Legal Next of Kin

      • Caregiver/Guardian


  • Any other individuals requesting information regarding the patient must receive authorization from the patient’s physician.

  • As a condition of employment, all personnel are cautioned not to discuss any information regarding patients with others. Casual comments with fellow co-workers throughout the institution may be overheard and violate the trust others have placed in our personnel and facility.

  • As required by state and federal law, information pertaining to victims of abuse/violence/sexual assault will be released to regulatory agencies.

  • As appropriate to state and federal law, any patient information requested by state and/or federal agencies will be released accordingly.

  • Information related to insurance benefits that may relate clinically to the patient will be released only upon proper identification of the requesting individual. All requests for patient information related to insurance coverage will be cleared through the Billing Department.

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