CR HIPAA Privacy
December 3, 2002
Revised April 3, 2003
NOTICE OF PRIVACY PRACTICES
FOR PROTECTED HEALTH INFORMATION
[45 CFR 164.520]
Background
The HIPAA Privacy Rule gives individuals a fundamental new right to be informed of the
privacy practices of their health plans and of most of their health care providers, as well as to be
informed of their privacy rights with respect to their personal hea
lth information. Health plans
and covered health care providers are required to develop and distribute a notice that provides a
clear explanation of these rights and practices. The notice is intended to focus individuals on
privacy issues and concerns, and to prompt them to have discussions with their health plans and
health care providers and exercise their rights. The Privacy Rule provides that an individual has a right to adequate notice
of how a covered entity may use and disclose protected health information about the individual,
as well as his or her rights and the covered entity’s obligations with respect to that information. Most covered entities must develop and provide individuals with this notice of their privacy
practices. The Privacy Rule does not require the following covered entities to develop a notice:
C Health care clearinghouses, if the only protected health information they create or
receive is as a business associate of another covered entity. See 45 CFR
164.500(b)(1). C A correctional institution that is a covered entity (e.g., that has a covered health
care provider component). C A group health plan that provides benefits only through one or more contracts of
insurance with health insurance issuers or HMOs, and that does not create or
receive protected health information other than summary health information or
enrollment or disenrollment information. See 45 CFR 164.520(a). Content of the Notice. Covered entities are required to provide a notice in plain language
that describes:
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OCR HIPAA Privacy
December 3, 2002
Revised April 3, 2003
C How the covered entity may use and disclose protected health information about
an individual. C The individual’s rights with respect to the information and how the individual
may exercise these rights, including how the individual may complain to the
covered entity. C The covered entity’s legal duties with respect to the information, including a
statement that the covered entity is required by law to maintain the privacy of
protected health information. C Whom individuals can contact for further information about the covered entity’s
privacy policies. The notice must include an effective date. See 45 CFR 164.520(b) for the specific
requirements for developing the content of the notice. A covered entity is required to promptly revise and distribute its notice whenever it makes
material changes to any of its privacy practices. See 45 CFR 164.520(b)(3), 164.520(c)(1)(i)(C)
for health plans, and 164.520(c)(2)(iv) for covered health care providers with direct treatment
relationships with individuals. Providing the Notice. C A covered entity must make its notice available to any person who asks for it. C A covered entity must prominently post and make available its notice on any web
site it maintains that provides information about its customer services or benefits. C Health Plans must also:
< Provide the notice to individuals then covered by the plan no later than
April 14, 2003 (April 14, 2004, for small health plans) and to new
enrollees at the time of enrollment.
< Provide a revised notice to individuals then covered by the plan within 60
days of a material revision.
< Notify individuals then covered by the plan of the availability of and how
to obtain the notice at least once every three years. C Covered Direct Treatment Providers must also:
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OCR HIPAA Privacy
December 3, 2002
Revised April 3, 2003
< Provide the notice to the individual no later than the date of first service
delivery (after the April 14, 2003 compliance date of the Privacy Rule)
and, except in an emergency treatment situation, make a good faith effort
to obtain the individual’s written acknowledgment of receipt of the notice. If an acknowledgment cannot be obtained, the provider must document his
or her efforts to obtain the acknowledgment and the reason why it was not
obtained.
< When first service delivery to an individual is provided over the Internet,
through e-mail, or otherwise electronically, the provider must send an
electronic notice automatically and contemporaneously in response to the
individual’s first request for service. The provider must make a good faith
effort to obtain a return receipt or other transmission from the individual in
response to receiving the notice.
< In an emergency treatment situation, provide the notice as soon as it is
reasonably practicable to do so after the emergency situation has ended. In
these situations, providers are not required to make a good faith effort to
obtain a written acknowledgment from individuals.
< Make the latest notice (i.e., the one that reflects any changes in privacy
policies) available at the provider’s office or facility for individuals to
request to take with them, and post it in a clear and prominent location at
the facility. C A covered entity may e-mail the notice to an individual if the individual agrees to
receive an electronic notice. See 45 CFR 164.520(c) for the specific requirements for providing the notice. Organizational Options. C Any covered entity, including a hybrid entity or an affiliated covered entity, may
choose to develop more than one notice, such as when an entity performs different
types of covered functions (i.e., the functions that make it a health plan, a health
care provider, or a health care clearinghouse) and there are variations in its
privacy practices among these covered functions. Covered entities are encouraged
to provide individuals with the most specific notice possible. C Covered entities that participate in an organized health care arrangement may
choose to produce a single, joint notice if certain requirements are met. For
example, the joint notice must describe the covered entities and the service
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