Standards for Privacy of Individually Identifiable Health Information. Final Privacy Rule Preamble.. Section 164.508(e) - Authorizations Requested by a Covered Entity for Disclosures by Others

12/28/2000

In the proposed rule, we would have prohibited all covered entities from requiring the individual's written legal permission (as proposed, an "authorization") for the use or disclosure of protected health information to carry out treatment, payment, or health care operations. We generally eliminate this prohibition in the final rule, except to specify that a consent obtained by one covered entity is not effective to permit another covered entity to use or disclose protected health information. See § 164.506(a)(5) and the corresponding preamble discussion.

In the final rule, if a covered entity seeks the individual's written legal permission to obtain protected health information about the individual from another covered entity for any purpose, it must obtain the individual's authorization for the covered entity that maintains the protected health information to make the disclosure. If the authorization is for the purpose of obtaining protected health information for purposes other than treatment, payment, or health care operations, the authorization need only contain the core elements required by § 164.508(c) and described above.

If the authorization, however, is for the purpose of obtaining protected health information to carry out treatment, payment, or health care operations, the authorization must meet the requirements of § 164.508(e). We expect such authorizations will rarely be necessary, because we expect covered entities that maintain protected health information to obtain consents that permit them to make anticipated uses and disclosures for these purposes. An authorization obtained by another covered entity that authorizes the covered entity maintaining the protected health information to make a disclosure for the same purpose, therefore, would be unnecessary.

We recognize, however, that these authorizations may be useful to demonstrate an individual's intent and relationship to the intended recipient of the information when the intent or relationship is not already clear. For example, a long term care insurer may need information from an individual's health care providers about the individual's ability to perform activities of daily living in order to determine payment of a long term care claim. The providers that hold the information may not be providing the long term care and may not, therefore, be aware of the individual's coverage under the policy or that the individual is receiving long term care services. An authorization obtained by the long term care insurer will help to demonstrate these facts to the providers holding the information, which will make them more confident that the individual intends for the information to be shared. Similarly, an insurer with subrogation obligations may need health information from the enrollee's providers to assess or prosecute the claim. A patient's new physician may also need medical records from the patient's prior providers in order to treat the patient. Without an authorization that demonstrates the patient's intent for the information to be shared, the covered entity that maintains the protected health information may be reluctant to provide the information, even if that covered entity's consent permits such disclosure to occur.

These authorizations may also be useful to accomplish clinical coordination and integration among covered entities that do not meet the definitions of affiliated covered entities or organized health care arrangements. For example, safety-net providers that participate in the Community Access Program (CAP) may not qualify as organized health care arrangements but may want to share protected health information with each other in order to develop and expand integrated systems of care for uninsured people. An authorization under this section would permit such providers to receive protected health information from other CAP participants to engage in such activities.

Because of such concerns, we permit a covered entity to request the individual's authorization to obtain protected health information from another covered entity to carry out treatment, payment, and health care operations. In these situations, the authorization must contain the core elements described above and must also describe each purpose of the requested disclosure.

With one exception, the authorization must also indicate that the authorization is voluntary. It must state that the individual may refuse to sign the authorization and that the covered entity requesting the authorization will not condition the provision of treatment, payment, enrollment in the health plan, or eligibility for benefits on obtaining the individual's authorization. If the authorization is for a disclosure of information that is necessary to determine payment of a claim for specified benefits, however, the health plan requesting the authorization may condition the payment of the claim on obtaining the authorization from the individual. See § 164.508(b)(4)(iii). In this case, the authorization does not have to state that the health plan will not condition payment on obtaining the authorization.

The covered entity requesting the authorization must provide the individual with a copy of the signed authorization. We note that the covered entity requesting the authorization is also subject to the requirements in § 164.514 to request only the minimum necessary information needed for the purpose of the authorization.

We additionally note that, when the covered entity that maintains the protected health information has already obtained a consent for disclosure of protected health information to carry out treatment, payment, and/or health care operations under § 164.506, and that consent conflicts with an authorization obtained by another covered entity under § 164.508(e), the covered entity maintaining the protected health information is bound by the more restrictive document. See § 164.506(e) and the corresponding preamble discussion for further explanation.