Workforce Training

It is the Company’s policy to train all members of its workforce who have access to PHI on its privacy policies and procedures. All staff members receive HIPAA training. Whenever a privacy incident has occurred, the Privacy Officer in collaboration with management will evaluate the occurrence to determine whether additional staff training is in order. Depending upon the situation, the Privacy Officer may determine that all staff should receive training that is specific to the privacy incident. The Privacy Officer will review any privacy training developed as part of a privacy incident resolution to ensure the materials adequately address the circumstances regarding the privacy incident and reinforce the Company’s privacy policies and procedures.

The Company has established technical and physical safeguards to prevent PHI from intentionally or unintentionally being used or disclosed in violation of HIPAA’s requirements. Technical safeguards include limiting access to information by creating computer firewalls. Physical safeguards include locking doors or filing cabinets and periodically changing door access codes. Additionally all staff members can only access PHI by using their own login information. Firewalls ensure that only authorized employees will have access to PHI, that they will have access to only the minimum amount of PHI necessary for their job functions, and that they will not further use or disclose PHI in violation of HIPAA’s privacy rules.

Currently all data in the local data center is backed up using industry standards with off-site storage of media. IBAA currently utilizes technology that allows the IT team to quickly remove, disable and start staff member access to PHI.

The Privacy Officer is responsible for developing and maintaining a notice of the Company’s privacy practices that describes:
• the uses and disclosures of PHI that may be made by the Company;
• the individual’s rights; and
• the Company’s legal duties with respect to the PHI.

The privacy notice will inform participants that the Company will have access to PHI. The privacy notice will also provide a description of the Company’s complaint procedures, the name and telephone number of the contact person for further information, and the date of the notice. The notice of privacy practices will be individually delivered to all participants:
• on an ongoing basis, at the time of an individual’s enrollment into a Company program or at the time of treatment and consent; and
• within 60 days after a material change to the notice.

The Company will also provide notice of availability of the privacy notice at least once every three years.

The Privacy Officer will be the Company’s contact person for receiving complaints. The Privacy Officer is responsible for creating a process for individuals to lodge complaints about the Company’s privacy procedures and for creating a system for handling such complaints. A copy of the complaint form shall be provided to any participant upon request.

Sanctions for using or disclosing PHI in violation of this HIPAA Privacy Plan will be imposed in accordance up to and including termination.

IBAA shall mitigate, to the extent possible, any harmful effects that become known to it because of a use or disclosure of an Participant’s PHI in violation of the policies and procedures set forth in this Plan. As a result, if an employee becomes aware of a disclosure of protected health information, either by a staff member of the Company or an outside consultant/contractor that is not in compliance with this Policy, immediately contact the Privacy Officer so that the appropriate steps to mitigate the harm to the participant can be taken.

No employee may intimidate, threaten, coerce, discriminate against, or take other retaliatory action against individuals for exercising their rights, filing a complaint, participating in an investigation, or opposing any improper practice under HIPAA. No individual shall be required to waive his or her privacy rights under HIPAA as a condition of treatment, payment, enrollment or eligibility.

The policy document includes provisions to describe the permitted and required uses and disclosures of PHI by IBAA. Specifically, the policy document requires IBAA to:
• not use or further disclose PHI other than as permitted by the Plan documents or as required by law;
• ensure that any agents or subcontractors to whom it provides PHI received from the Company agree to the same restrictions and conditions that apply to Axis;
• report to the Privacy Officer any use or disclosure of the information that is inconsistent with the permitted uses or disclosures;
• make PHI available to Participants, consider their amendments and, upon request, provide them with an accounting of PHI disclosures;
• make the Company’s internal practices and records relating to the use and disclosure of PHI received by the Company available to the Department of Health and Human Services (DHHS) upon request

The Company’s privacy policies and procedures shall be documented and maintained for at least six years. Policies and procedures must be changed as necessary or appropriate to comply with changes in the law, standards, requirements and implementation specifications (including changes and modifications in regulations). Any changes to policies or procedures must be promptly documented.

If a change in law impacts the privacy notice, the privacy policy must promptly be revised and made available. Such change is effective only with respect to PHI created or received after the effective date of the notice. IBAA shall document certain events and actions (including authorizations, requests for information, sanctions, and complaints) relating to an individual’s privacy rights. The documentation of any policies and procedures, actions, activities and designations may be maintained in either written or electronic form.

Incident Report

The Company has developed an Incident Report form. This form is used to document reports of privacy breaches that have been referred to the Privacy Officer from staff members who have reviewed or received the suspected incident. After receiving the Incident Report form from staff members, the Privacy Officer classifies the incident and its severity and analyzes the situation. Documentation shall be retained by the Company for a minimum of six years from the date of the reported incident. If the Privacy Officer is able to resolve the incident, the Privacy Officer shall also document the actions taken to resolve the issue in the Incident Report form.

Electronic Health Records

Just like paper records, Electronic Health Records must comply with HIPAA, and other state and federal laws. Unlike paper records, electronic health records can be encrypted – using technology that makes them unreadable to anyone other than an authorized user – and security access parameters are set so that only authorized individuals can view them. Further, EHRs offer the added security of an electronic tracking system that provides an accounting history of when records have been accessed and who accessed them.

Access Authorization

IBAA will grant access to PHI based on their job functions and responsibilities. The Privacy Officer in collaboration with IT is responsible for the determination of which individuals require access to PHI and what level of access they require through discussions with the individual’s manager. The IT department will keep a record of authorized users and the rights that they have been granted with respect to PHI. IT keeps a comprehensive matrix of how and to who rights are granted.

Use and Disclosure Defined

The Company will use and disclose PHI only as permitted under HIPAA. The terms “use” and “disclosure” are defined as follows:

 Use. The sharing, employment, application, utilization, examination, or analysis of individually identifiable health information by any person working for or within the Company, or by a Business Associate of the Company.
• Disclosure. For information that is protected health information, disclosure means any release, transfer, provision of access to, or divulging in any other manner of individually identifiable health information to persons not employed by or working within Axis with a business need to know PHI.

Access to PHI Is Limited to Certain Employees

All staff who performs Participant functions directly on behalf of the Company or on behalf of group health plans will have access to PHI as determined by their department and job description and as granted by IT. These employees with access may use and disclose PHI as required under HIPAA but the PHI disclosed must be limited to the minimum amount necessary to perform the job function. Employees with access may not disclose PHI unless an approved compliant authorization is in place or the disclosure otherwise is in compliance with this Plan and the use and disclosure procedures of HIPAA. Staff members may not access either through our information systems or the participant’s medical record the medical and/or demographic information for themselves, family members, friends, staff members or other individuals for personal or other non-work related purposes, even if written or oral participant authorization has been given. If the staff member is a Participant in IBAA’s plans, the staff member must go through their Provider in order to request their own PHI. In the very rare circumstance when a staff member’s job requires him/her to access and/or copy the medical information of a family member, a staff member, or other personally known individual, then he/she should immediately report the situation to his/her manager who will determine whether to assign a different staff member to complete the task involving the specific Participant. Your access to your own PHI must be based on the same procedures available to other participants not based on your job-related access to our information systems. You cannot access your own information; you must go through all the appropriate channels as any Participant would have to.

Disclosures of PHI Pursuant to an Authorization

PHI may be disclosed for any purpose if an authorization that satisfies all of HIPAA’s requirements for a valid authorization is provided by the participant. All uses and disclosures made pursuant to a signed authorization must be consistent with the terms and conditions of the authorization.

Permissive Disclosures of PHI: for Legal and Public Policy Purposes

PHI may be disclosed in the following situations without a participant’s authorization, when specific requirements are satisfied. The Company’s use and disclosure procedures describe specific requirements that must be met before these types of disclosures may be made. Permitted are disclosures:
• about victims-of abuse, neglect or domestic violence;
• for judicial and administrative proceedings;
• for law enforcement purposes;
• for public health activities;
• for health oversight activities;
• about decedents;
• for cadaver organ, eye or tissue donation purposes;
• for certain limited research purposes;
• to avert a serious threat to health or safety;
• for specialized government functions; and
• that relate to workers’ compensation programs.

Complying With the “Minimum-Necessary” Standard

HIPAA requires that when PHI is used or disclosed, the amount disclosed generally must be limited to the “minimum necessary” to accomplish the purpose of the use or disclosure. The “minimum-necessary” standard does not apply to any of the following:
• uses or disclosures made to the individual;
• uses or disclosures made pursuant to a valid authorization;
• disclosures made to the Department of Labor;
• uses or disclosures required by law; and
• uses or disclosures required to comply with HIPAA.

Minimum Necessary When Disclosing PHI. For making disclosures of PHI to any business associate or providers, or internal/external auditing purposes, only the minimum necessary amount of information will be disclosed. All other disclosures must be reviewed on an individual basis with the Privacy Officer to ensure that the amount of information disclosed is the minimum necessary to accomplish the purpose of the disclosure.

Minimum Necessary When Requesting PHI. For making requests for disclosure of PHI from business associates, providers or participants for purposes of claims payment/adjudication or internal/external auditing purposes, only the minimum necessary amount of information will be requested. All other requests must be reviewed on an individual basis with the Privacy Officer to ensure that the amount of information requested is the minimum necessary to accomplish the purpose of the disclosure.

Disclosures of PHI to Business Associates

With the approval of the Privacy Officer and in compliance with HIPAA, employees may disclose PHI to the Company’s business associates and allow the Company’s business associates to create or receive PHI on its behalf. However, prior to doing so, the Company must first obtain assurances from the business associate that it will appropriately safeguard the information. Before sharing PHI with outside consultants or contractors who meet the definition of a “business associate,” employees must contact the Privacy Officer and verify that a business associate contract is in place. Business Associate is an entity that:
• performs or assists in performing a Company function or activity involving the use and disclosure of protected health information (including claims processing or administration, data analysis, underwriting, etc.); or
• provides legal, accounting, actuarial, consulting, data aggregation, management, accreditation, or financial services, where the performance of such services involves giving the service provider access to PHI.

Examples of Business Associates are:
• A third party administrator that assists the Company with claims processing.
• A CPA firm whose accounting services to a health care provider involves access to protected health information.
• An attorney whose legal services involve access to protected health information.
• A consultant that performs utilization reviews for the Company.
• A health care clearinghouse that translates a claim from a non-standard format into a standard transaction on behalf of the Company and forwards the processed transaction to a payer.
• An independent medical transcriptionist that provides transcription services for the Company.
• A pharmacy benefits manager that manages a health plan’s pharmacist network.

Disclosures of De-Identified Information

The Company may freely use and disclose de-identified information. De-identified information is health information that does not identify an individual and with respect to which there is no reasonable basis to believe that the information can be used to identify an individual. There are two ways a covered entity can determine that information is de-identified: either by professional statistical analysis, or by removing 18 specific identifiers.
1. Names
2. Geographic subdivisions smaller than a state
3. All elements of dates (except year) related to an individual – including dates of admission, discharge, birth, death – and for persons >89 y.o., the year of birth cannot be used.
4. Telephone numbers
5. FAX numbers
6. Electronic mail addresses
7. Social Security Number
8. Medical Record numbers
9. Health plan beneficiary numbers
10. Account numbers
11. Certificate/license numbers
12. Vehicle identifiers and serial numbers including license plates
13. Device identifiers and serial numbers
14. Web URLs
15. Internet protocol addresses
16. Biometric identifiers, including finger and voice prints
17. Full face photos, and comparable images
18. Any unique identifying number, characteristic or code

Disclosures to Family, Friends or Others-Participant Location

There are instances when a participant’s friend or family member contacts IBAA to ask about the location of a patient or whether the patient has been seen at IBAA. Following is guidance provided to assist staff in providing appropriate responses for specific situations that commonly occur. In rare cases of emergency, at the discretion of the Director the minimum of information may be released in order to assist in resolving an emergency situation.

Guidance

Situation: Friends or family are concerned about the whereabouts of a person. They contact the company to ask if a person is at IBAA or has been seen as a participant recently.

Response:
If the person is not currently an IBAA participant, the caller may be told that the person is not at the clinic. If the person is currently receiving services at the clinic, clinic staff should take the name of the caller, their purpose for calling the participant and tell them that they will check. Staff should then ask the participant or guardian if it is okay to provide information to the caller and what information to provide. If the patient does not want the clinic staff to provide information, staff should tell the caller that they are unable to provide information about the participant due to privacy rights and suggest that the caller contact the participant or guardian directly for information. If the caller is asking for historical information about visits or services provided and the participant has not either provided an authorization to share this information with this person pertaining to their involvement in the patient’s treatment or payment, the caller should be informed that due to HIPAA confidentiality requirements, information about participant visits is not provided without participant authorization.

Situation: An individual comes to IBAA and tells the reception area that they have arrived to pick up a patient.

Response:
If the participant or guardian has notified IBAA staff that someone is coming to pick them up (by giving the name of the individual), the individual should be directed to the location of the participant. If the participant or guardian has not provided information about anyone coming to pick them up, IBAA staff should ask for the person’s name and tell the person that they will check. The staff member will examine the approved drop-off/pick up list. If individual is not listed, staff member should tell the participant or call the guardian that someone has arrived to pick them up and ask them whether it is okay to tell the person the participant’s location.

Removing PHI from Company Premises

When IBAA deems it necessary for an employee to work from a location other than our site, PHI may be accessed and/or removed under the following circumstances:
1. Before removing PHI from IBAA for company business you must receive the approval from your department Director and IT.
2. IBAA will only allow the paper (participant records, reports) removal of PHI when transported in a secure lock box and when approved by the department Director and the Privacy Officer.
3. IBAA will provide laptop computers for employees required to work offsite and access PHI in a non-IBAA setting. Any files saved on these computers are saved to the network and are therefore secure.
4. Staff members that work at school sites and create paper files at the school are required to keep these files locked securely. While in transit, these files are kept locked in secured carrying cases.
5. Staff member with progress notes and other forms that need to be signed by their supervisors can be brought back to IBAA in a locked carrying case. These documents can also be saved on the Axis server in a designated secure file on the company network, or on a password-protected flash drive received by IT.
6. The electronic removal of PHI (using flash drives) for the purposes of working from a non-IBAA setting may be approved in advance by IT only. In the very rare circumstance that it becomes necessary, the PHI should be rigorously safeguarded physically as well as electronically, including employee-performed encryption of all files. Most flash drives have the capability to assign a password.
7. The following safeguards are required of all employees when working from a non-IBAA site:
• When outside the facility, only work on health information in a secure private environment.
• Keep the information with you at all times while in transit.
• Do not permit others to have access to the information.
• Never email participant information.
• Don’t save participant information to your home computer.
• Do not print records of any type.
• Do not record login information on or near the computer.
• Return all information the next business day or as soon as required.

IBAA will immediately investigate any incident that involves the loss or theft of PHI that was taken off-site.

Faxing PHI

Each fax should be accompanied by an IBAA fax cover sheet. Faxing of highly confidential information is not recommended. Faxing of highly confidential information is only permitted if the sender first calls the recipient and confirms that the recipient or his/her designee can be waiting at the fax machine, and then, the recipient or his/her designee waits at the fax machine to receive the fax and then calls the sender to confirm receipt of the document. Both the sender and the recipient must be attentive to the sensitive nature of highly confidential information.

If the fax was transmitted to the wrong recipient, in all cases follow these steps:
Fax a request to the incorrect fax number explaining that the information has been misdirected, and ask that the materials be returned or destroyed. Document the incident on an Incident Report Form and notify the HIPAA Privacy Officer at (765) 419-0411. Verify the fax number with the recipient before attempting to fax the information again.

Storage of PHI

All PHI in use will be closed, covered or placed in a position to minimize incidental disclosure. If being viewed by a computer or electronic device, PHI will be oriented in a way so that information on display is not easily viewed by unauthorized persons. When not in use, these devices should be logged out of to ensure that the information is not being used improperly.

EPHI is kept securely via a network server that is password-protected and encrypted. Mobile devices will be password-protected and encrypted.
If PHI is authorized to be sent via e-mail, a test e-mail not including PHI will be sent to the recognized address prior to the PHI being released in order to ensure the appropriate receiver. Once a response has been received, a secure message will be sent via Barracuda that will be password protected. Barracuda has a timed session. If there is no activity detected, it will automatically log the user out.

Paper PHI is stored in the Business Office under lock and key. There will be a lock contained on the filing cabinet, and also on the Business Office door. If paper PHI is requested by a staff member, that staff member must notify the Office Manager or Billing Specialist of the need prior to removing it from the office. All paper PHI charts are labelled with an encrypted name to ensure the security of the participant.

Past paper PHI will be stored on the premises inside labelled boxes under lock and key for the amount of time required by HIPAA. Each box is numbered, and a log book identifies all materials inside each box.

Access to Protected Health Information and Requests for Amendment

HIPAA gives participants the right to access and obtain copies of their PHI that the Company or its business associates maintains. HIPAA also provides that participants may request to have their PHI amended. The Company will provide access to PHI and it will consider requests for amendment that are submitted in writing by participants.

Accounting

An individual has the right to obtain an accounting of certain disclosures of his or her own PHI. This right to an accounting extends to disclosures made in the last six years, other than disclosures:
• to carry out treatment, payment or health care operations;
• to individuals about their own PHI;
• incident to an otherwise permitted use or disclosure or pursuant to an authorization;
• for purposes of creation of a facility directory or to persons involved in the participant’s care or other notification purposes;
• as part of a limited data set; or
• for other national security or law enforcement purposes.

The Company shall respond to an accounting request within 60 days. If the Company is unable to provide the accounting within 60 days, it may extend the period by 30 days, provided that it gives the participant notice (including the reason for the delay and the date the information will be provided) within the original 60-day period.

The accounting must include the date of the disclosure, the name of the receiving party, a brief description of the information disclosed, and a brief statement of the purpose of the disclosure (or a copy of the written request for disclosure, if any).

The first accounting in any 12-month period shall be provided free of charge. The Privacy Officer may impose reasonable production and mailing costs for subsequent accountings. The Privacy Officer is responsible for responding to a request for Accounting.

Requests for Alternative Communication Means or Locations
Participants may request to receive communications regarding their PHI by alternative means or at alternative locations. For example, participants may ask to be called only at work rather than at home. Such requests may be honored if, in the sole discretion of IBAA, the requests are reasonable.

However, IBAA shall accommodate such a request if the participant clearly provides information that the disclosure of all or part of that information could endanger the participant. The Privacy Officer in collaboration with managers has responsibility for administering requests for confidential communications.

Requests for Restrictions on Uses and Disclosures of Protected Health Information

A participant may request restrictions on the use and disclosure of the participant’s PHI. It is the Company’s policy to attempt to honor such requests if, in the sole discretion of the Company, the requests are reasonable. The Privacy Officer is charged with responsibility for processing requests for restrictions.

When a Participant Requests a Copy of his/her Record

A participant can request a copy of his/her medical record by completing a Release of Information form and submitting it to the Department that maintains the information being requested. The Department in collaboration with the Privacy Officer must process and respond to the request within 7 business days.

Acceptable Methods of Verification of Identity for Release of Personal Health Information (PHI):

When the Requestor is the Participant
The Company will take reasonable steps and exercise professional judgment to verify the identity of the individual making a request for access to his/her child’s PHI.
a. If the request is made in person, verification of identity may be accomplished by asking for photo identification (such as a driver’s license). A copy of the I.D. must be attached to the request and placed in the Participants record.
b. If the request is made over the telephone, verification will be accomplished by requesting identifying information such as social security number, birth date, and medical record number and confirming that this information matches what is in the participant’s record. Or, verification will occur through a callback process using phone numbers documented in the participant record to validate the caller’s identity.
c. If the request is made in writing, verification will be accomplished by requesting a photocopy of photo identification if a photocopy of the ID is not available, the signature on the written request must be compared with the signature in the participant record. In addition, Axis will need to verify the validity of the written request by contacting the participant by telephone.

When the requestor is the Participants Legally Authorized Representative
Verification of identity will be accomplished by asking for a valid photo identification (such as driver’s license) if the request is made in person. Once identity is established, authority in such situations may be determined by confirming the person is named in the medical record or in the participant’s profile as the participant’s legally authorized representative. Or, if there is no person listed in the medical record as the participant’s legally authorized representative, authority may be established by the person presenting an original of a valid power of attorney for health care or a copy of a court order appointing the person guardian of the participant and a valid photo I.D. A copy of the I.D. and legal notice must be attached to the request and placed in the Participants record.

The Company may use any other method of verification that, in the Company’s discretion, is reasonably calculated to verify the identity of the person making the request. Some acceptable means of verification include, but are not limited to:
d. Requesting to see a photo ID
e. Requesting a copy of a power of attorney
f. Confirming personal information with the requestor such as date of birth, policy number or social security number
g. Questioning a child’s caretaker to establish the relationship with the child
h. Calling the requestor back through a main organization switchboard rather than a direct number

Breach Notification Requirements

Following a breach of unsecured protected health information, covered entities must provide notification of the breach to affected individuals if necessary and in certain circumstances, to the media. In addition, business associates must notify covered entities that a breach has occurred.

Individual Notice
Covered entities must notify affected individuals following the discovery of a breach of unsecured protected health information. Covered entities must provide this individual notice in written form by first-class mail, or alternatively, by e-mail if the affected individual has agreed to receive such notices electronically. If the covered entity has insufficient or out-of-date contact information for 10 or more individuals, the covered entity must provide substitute individual notice by either posting the notice on the home page of its web site or by providing the notice in major print or broadcast media where the affected individuals likely reside. If the covered entity has insufficient or out-of-date contact information for fewer than 10 individuals, the covered entity may provide substitute notice by an alternative form of written, telephone, or other means.

These individual notifications must be provided without unreasonable delay and in no case later than 60 days following the discovery of a breach and must include, to the extent possible, a description of the breach, a description of the types of information that were involved in the breach, the steps affected individuals should take to protect themselves from potential harm, a brief description of what the covered entity is doing to investigate the breach, mitigate the harm, and prevent further breaches, as well as contact information for the covered entity. Additionally, for substitute notice provided via web posting or major print or broadcast media, the notification must include a toll-free number for individuals to contact the covered entity to determine if their protected health information was involved in the breach.

Media Notice
Covered entities that experience a breach affecting more than 500 residents of a State or jurisdiction are, in addition to notifying the affected individuals, required to provide notice to prominent media outlets serving the State or jurisdiction. Covered entities will likely provide this notification in the form of a press release to appropriate media outlets serving the affected area. Like individual notice, this media notification must be provided without unreasonable delay and in no case later than 60 days following the discovery of a breach and must include the same information required for the individual notice.

Notice to the Secretary
In addition to notifying affected individuals and the media (where appropriate), covered entities must notify the Secretary of breaches of unsecured protected health information. Covered entities will notify the Secretary by visiting the HHS web site and filling out and electronically submitting a breach report form. If a breach affects 500 or more individuals, covered entities must notify the Secretary without unreasonable delay and in no case later than 60 days following a breach. If, however, a breach affects fewer than 500 individuals, the covered entity may notify the Secretary of such breaches on an annual basis. Reports of breaches affecting fewer than 500 individuals are due to the Secretary no later than 60 days after the end of the calendar year in which the breaches occurred.

Notification by a Business Associate
If a breach of unsecured protected health information occurs at or by a business associate, the business associate must notify the covered entity following the discovery of the breach. A business associate must provide notice to the covered entity without unreasonable delay and no later than 60 days from the discovery of the breach. To the extent possible, the business associate should provide the covered entity with the identification of each individual affected by the breach as well as any information required to be provided by the covered entity in its notification to affected individuals.

Complaint/Concerns Reporting

Concerns about the Company’s privacy practices may arise in a variety of contexts and may be received by many different persons at the Company. It is important that the Company responds to concerns and complaints in a timely manner. When a staff member hears or receives a complaint/concern, he/she should ask the complainant whether or not the complainant wishes to file a formal complaint and offer to assist the complainant with the form. Even if the person does not wish to file a complaint or provide identifying information, the staff member should proceed with the procedures outlined below.

Filing a Complaint

Participant’s complaints of alleged privacy rights violations may be forwarded through multiple channels, such as telephone calls, letter via mail/email, in person. If these complaints are received by a staff member the person receiving the complaint will:
• In response to a Telephone Call or In-Person Request to File a Complaint – Complete the Privacy Complaint Form and immediately forward to the Privacy Officer. Offer to forward a copy of the complaint form to the complainant.
• In response to a Letter or Email (print out) – Complete the Privacy Complaint Form and immediately forward to the Privacy Officer. Attach the written complaint to the complaint form.
• In response to an Anonymous Complaint– Complete the Privacy Complaint Form based on the information provided and immediately forward to the Privacy Officer. When possible, explain to the complainant that the Company has an obligation to follow up on complaints whether or not they are anonymously filed.

Staff Members – Call the Privacy Officer at (925) 201-6038. Staff members may also complete the Privacy Complaint Form and forward to the Privacy Officer. Staff members can also fill out the complaint form and put it in the Privacy Officers mail box located at 4361 Railroad Avenue, Suite E. Upon receipt of a complaint, the Privacy Officer will initiate primary investigation.
• Initial review – All complaints will be initially reviewed by the Privacy Officer or his/her designee to determine if the complaint alleges a violation of established policies and procedures or other known regulations regarding the protection of individually identifiable health information. If there is no legitimate allegation, the Privacy Officer will, when possible, contact the Complainant by letter and inform him/her of this finding within 60 days. All documentation will be maintained as prescribed in this policy.
• Complaints requiring further review – If there is a legitimate allegation, the Privacy Officer or his/her designee will conduct a detailed investigation by reviewing the covered University unit practices, contacting employees, students, or volunteers as needed, working with the Security Officer (as applicable), and utilizing other University resources as needed. Upon conclusion of the investigation, the Privacy Officer will, when possible, contact the Complainant by letter and inform him/her of the finding within 60 days.

  1. 60-day time frame – In the event that this 60-day period cannot be met, the Privacy Officer shall, when possible, communicate this determination to the Complainant in writing and include an estimated timeframe for completion of the investigation.
  2. Outcome of Investigation – The purpose of the investigation is to determine the compliance of the Company’s policies and procedures implementing the privacy standards mandated by HIPAA. The Company will mitigate, to the extent practicable, any harmful effect that is known of a use or disclosure of PHI in violation of the Company’s policies and procedures or HIPAA’s privacy requirements by the Company or any of its Business Associates. In the event that disciplinary action is recommended, the Privacy Officer or his/her designee will coordinate any action with management.
  3. Documentation – All complaints sent to the Privacy Officer shall be documented in a format that includes all of the information contained on the Privacy Complaint Form. The Privacy Officer will maintain all completed complaints’ documentation for six years from the initial date of the complaint

Non-Retaliation
The Company shall not intimidate, threaten, coerce, discriminate against, or take any other form of retaliatory action against any person who has reported a privacy incident.

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