The Privacy Rule permits, but does not require, a covered entity voluntarily to obtain patient consent for uses and disclosures of protected health information for treatment, payment, and health care operations. Covered entities that do so have complete discretion to design a process that best suits their needs.
By contrast, an “authorization” is required by the Privacy Rule for uses and disclosures of protected health information not otherwise allowed by the Rule. Where the Privacy Rule requires patient authorization, voluntary consent is not sufficient to permit a use or disclosure of protected health information unless it also satisfies the requirements of a valid authorization. An authorization is a detailed document that gives covered entities permission to use protected health information for specified purposes, which are generally other than treatment, payment, or health care operations, or to disclose protected health information to a third party specified by the individual.
An authorization must specify a number of elements, including a description of the protected health information to be used and disclosed, the person authorized to make the use or disclosure, the person to whom the covered entity may make the disclosure, an expiration date, and, in some cases, the purpose for which the information may be used or disclosed. With limited exceptions, covered entities may not condition treatment or coverage on the individual providing an authorization.
Does the HIPAA Privacy Rule permit doctors, nurses, and other health care providers to share patient health information for treatment purposes without the patient’s authorization?Lee Russell2020-09-10T21:12:07-04:00
Yes. The Privacy Rule allows those doctors, nurses, hospitals, laboratory technicians, and other health care providers that are covered entities to use or disclose protected health information, such as X-rays, laboratory and pathology reports, diagnoses, and other medical information for treatment purposes without the patient’s authorization. This includes sharing the information to consult with other providers, including providers who are not covered entities, to treat a different patient, or to refer the patient. See 45 CFR 164.506.
Can an authorization be used together with other written instructions from the intended recipient of the information?Lee Russell2020-09-06T14:33:35-04:00
A transmittal or cover letter can be used to narrow or provide specifics about a request for protected health information as described in an Authorization, but it cannot expand the scope of the Authorization.
For example, if an individual has authorized the disclosure of “all medical records” to an insurance company, the insurance company could by cover letter narrow the request to the medical records for the last 12 months. The cover letter could also specify a particular employee or address for the “class of persons” designated in the Authorization to receive the information. By contrast, an insurance company could not by cover letter extend the expiration date of an Authorization, or expand the scope of information set forth in the Authorization.
Does the Privacy Rule require that an authorization be notarized or include a witness signature?Lee Russell2020-09-06T14:33:10-04:00
Yes, provided that the Authorization encompasses the category of information that was later created, and that the Authorization has not expired or been revoked by the individual. Unless otherwise expressly limited by the Authorization, a covered entity may use or disclose the protected health information identified on the Authorization regardless of when the information was created.
Must an authorization include an expiration date?Lee Russell2020-09-06T14:32:10-04:00
The Privacy Rule requires that an Authorization contain either an expiration date or an expiration event that relates to the individual or the purpose of the use or disclosure. For example, an Authorization may expire “one year from the date the Authorization is signed,” “upon the minor’s age of majority,” or “upon termination of enrollment in the health plan.”
An Authorization remains valid until its expiration date or event, unless effectively revoked in writing by the individual before that date or event. The fact that the expiration date on an Authorization may exceed a time period established by State law does not invalidate the Authorization under the Privacy Rule, but a more restrictive State law would control how long the Authorization is effective.
Is a copy, facsimile, or electronically transmitted version of a signed authorization valid under the Privacy Rule?Lee Russell2020-09-06T14:31:44-04:00
Yes. Under the Privacy Rule, a covered entity may use or disclose protected health information pursuant to a copy of a valid and signed Authorization, including a copy that is received by facsimile or electronically transmitted.
Can an individual revoke his or her authorization?Lee Russell2020-09-06T14:31:14-04:00
Yes. The Privacy Rule gives individuals the right to revoke, at any time, an Authorization they have given. The revocation must be in writing, and is not effective until the covered entity receives it. In addition, a written revocation is not effective with respect to actions a covered entity took in reliance on a valid Authorization, or where the Authorization was obtained as a condition of obtaining insurance coverage and other law provides the insurer with the right to contest a claim under the policy or the policy itself.
The Privacy Rule requires that the Authorization must clearly state the individual’s right to revoke; and the process for revocation must either be set forth clearly on the Authorization itself, or if the covered entity creates the Authorization, and its Notice of Privacy Practices contains a clear description of the revocation process, the Authorization can refer to the Notice of Privacy Practices. Authorization forms created by or submitted through a third party should not imply that revocation is effective when the third party receives it, since the revocation is not effective until a covered entity which had previously been authorized to make the disclosure receives it.
May a valid authorization list categories of persons who may use or disclose protected health information, without naming specific individuals or entities?Lee Russell2020-09-06T14:30:48-04:00
Yes. One Authorization form may be used to authorize uses and disclosures by classes or categories of persons or entities, without naming the particular persons or entities. See 45 CFR 164.508(c)(1)(ii). For example, it would be sufficient if an Authorization authorized disclosures by “any health plan, physician, health care professional, hospital, clinic, laboratory, pharmacy, medical facility, or other health care provider that has provided payment, treatment or services to me or on my behalf” or if an Authorization authorized disclosures by “all medical sources.” A separate Authorization specifically naming each health care provider from whom protected health information may be sought is not required.
Similarly, the Rule permits the identification of classes of persons to whom the covered entity is authorized to make a disclosure. See 45 CFR 164.508(c)(1)(iii). Thus, a valid Authorization may authorize disclosures to a particular entity, particular person, or class of persons, such as “the employees of XYZ division of ABC insurance company.”
Does the Privacy Rule permit a covered entity to use or disclose protected health information pursuant to an authorization form that was prepared by a third party?Lee Russell2020-09-06T14:29:31-04:00
Yes. A covered entity is permitted to use or disclose protected health information pursuant to any Authorization that meets the Privacy Rule’s requirements at 45 CFR 164.508. The Privacy Rule requires that an Authorization contain certain core elements and statements, but does not specify who may draft an Authorization (i.e., it could be drafted by any entity) or dictate any particular format for an Authorization. Thus, a covered entity may disclose protected health information as specified in a valid Authorization that has been created by another covered entity or a third party, such as an insurance company or researcher.
May a covered entity use or disclose a patient’s entire medical record based on the patient’s signed authorization?Lee Russell2020-09-06T14:28:50-04:00
Yes, as long as the Authorization describes, among other things, the information to be used or disclosed by the covered entity in a “specific and meaningful fashion,” and is otherwise valid under the Privacy Rule. See 45 CFR 164.508(b)(1) and 164.508(c)(1)(i).
An Authorization would be valid if it authorized the covered entity to use or disclose an “entire medical record” or “complete patient file.” On the other hand, without further definition, an Authorization to use or disclose “all protected health information” might not be sufficiently specific, since protected health information encompasses a wider range of information than that which is typically understood to be included in the medical record, and individuals are less likely to understand the breadth of information that may be defined as “protected health information.”
Can covered entities continue to disclose protected health information to the HHS Office for Human Research Protections for purposes of determining compliance with the HHS regulations for the protection of human subjects (45 CFR Part 46)?Lee Russell2020-09-09T00:05:16-04:00
Yes. The Office for Human Research Protections is a health oversight agency under the HIPAA Privacy Rule. Therefore, covered entities can continue to disclose protected health information to the Office for Human Research Protections for such compliance investigations either with patient authorization as provided at 45 CFR 164.508, or without patient authorization for health oversight activities as permitted at 45 CFR 164.512(d).
Can covered entities continue to disclose adverse event reports that contain protected health information to the Department of Health and Human Services (HHS) Office for Human Research Protections?Lee Russell2020-09-09T00:05:16-04:00
Yes. The Office for Human Research Protections is a public health authority under the HIPAA Privacy Rule. Therefore, covered entities can continue to disclose protected health information to report adverse events to the Office for Human Research Protections either with patient authorization as provided at 45 CFR 164.508, or without patient authorization for public health activities as permitted at 45 CFR 164.512(b).
If research subjects’ consent was obtained before the compliance date, but the Institutional Review Board (IRB) subsequently modifies the informed consent document after the compliance date and requires that subjects be reconsented, is authorization now required from these previously enrolled research subjects under the HIPAA Privacy Rule?Lee Russell2020-09-10T20:02:47-04:00
Yes. If informed consent or reconsent (ie., asked to sign a revised consent or another informed consent) is obtained from research subjects after the compliance date, the covered entity must obtain individual authorization as required at 45 CFR 164.508 for the use or disclosure of protected health information once the consent obtained before the compliance date is no longer valid for the research. The revised informed consent document may be combined with the authorization elements required by 45 CFR 164.508.
Does the HIPAA Privacy Rule require documentation of Institutional Review Board (IRB) or Privacy Board approval of an alteration or waiver of individual authorization before a covered entity may use or disclose protected health information for any of the following provisions: (1) for preparatory research at 45 CFR 164.512(i)(1)(ii), (2)for research on the protected health information of decedents at 45 CFR 164.512(i)(1)(iii), or (3) a limited data set with a data use agreement as stipulated at 45 CFR 164.51?Lee Russell2020-09-08T17:21:27-04:00
No. Documentation of IRB or Privacy Board approval of an alteration or waiver of individual authorization is only needed before a covered entity may use or disclose protected health information under 45 CFR 164.512(i)(1)(i).
Can the preparatory research provision of the HIPAA Privacy Rule at 45 CFR 164.512(i)(1)(ii) be used to recruit individuals into a research study?Lee Russell2020-09-08T17:21:11-04:00
The preparatory research provision permits covered entities to use or disclose protected health information for purposes preparatory to research, such as to aid study recruitment. However, the provision at 45 CFR 164.512(i)(1)(ii) does not permit the researcher to remove protected health information from the covered entity’s site. As such, a researcher who is an employee or a member of the covered entity’s workforce could use protected health information to contact prospective research subjects.
The preparatory research provision would allow such a researcher to identify prospective research participants for purposes of seeking their authorization to use or disclose protected health information for a research study. In addition, the Rule permits a covered entity to disclose protected health information to the individual who is the subject of the information. See 45 CFR 164.502(a)(1)(i).
However, a researcher who is not a part of the covered entity may not use the preparatory research provision to contact prospective research subjects. Rather, the outside researcher could obtain contact information through a partial waiver of individual authorization by an IRB or Privacy Board as permitted at 45 CFR164.512(i)(1)(i). The IRB or Privacy Board waiver of authorization permits the partial waiver of authorization for the purposes of allowing a researcher to obtain protected health information as necessary to recruit potential research subjects. For example, even if an IRB does not waive informed consent and individual authorization for the study itself, it may waive such authorization to permit the disclosure of protected health information as necessary for the researcher to be able to contact and recruit individuals into the study.
If a research subject revokes his or her authorization to have protected health information used or disclosed for research, does the HIPAA Privacy Rule permit a researcher/covered health care provider to continue using the protected health information already obtained prior to the time the individual revoked his or her authorization?Lee Russell2020-09-08T17:20:16-04:00
Covered entities may continue to use and disclose protected health information that was obtained prior to the time the individual revoked his or her authorization, as necessary to maintain the integrity of the research study. An individual may not revoke an authorization to the extent the covered entity has acted in reliance on the authorization. For research uses and disclosures, this reliance exception at 45 CFR 164.508(b)(5)(i) permits the continued use and disclosure of protected health information already obtained pursuant to a valid authorization to the extent necessary to preserve the integrity of the research study. For example, the reliance exception would permit the continued use and disclosure of protected health information to account for a subject’s withdrawal from the research study, as necessary to incorporate the information as part of a marketing application submitted to the Food and Drug Administration, to conduct investigations of scientific misconduct, or to report adverse events.
However, the reliance exception would not permit a covered entity to continue disclosing additional protected health information to a researcher or to use for its own research purposes information not already gathered at the time an individual withdraws his or her authorization.
When does a covered entity have discretion to determine whether a research component of the entity is part of their covered functions, and therefore, subject to the HIPAA Privacy Rule?Lee Russell2020-09-08T17:19:34-04:00
A covered entity that qualifies as a hybrid entity, meaning that the entity is a single legal entity that performs both covered and non-covered functions, may choose whether it wants to be a hybrid entity. If such a covered entity decides not to be a hybrid entity then it, and all of its components, are subject to the Privacy Rule in its entirety. Therefore, if a researcher is an employee or workforce member of a covered entity that has decided not to be a hybrid entity, the researcher is part of the covered entity and is, therefore, subject to the Privacy Rule.
If a covered entity decides to be a hybrid entity, it must define and designate its health care component(s). Research components of a hybrid entity that function as health care providers and engage in standard electronic transactions must be included in the hybrid entity’s health care component(s), and be subject to the Privacy Rule.
However, research components that function as health care providers, but do not engage in standard electronic transactions may, but are not required to, be included in the health care component(s) of the hybrid entity. For example, a hybrid entity, such as a university, has the option to include or exclude a research laboratory, that functions as a health care provider but does not engage in electronic transactions, as part of the hybrid entity’s health care component. If such a research laboratory is included in the hybrid entity’s health care component, then the employees or workforce members of the laboratory must comply with the Privacy Rule. But if the research laboratory is excluded from the hybrid entity’s health care component, the employees or workforce members of the laboratory are not subject to the Privacy Rule.
When is a researcher considered to be a covered health care provider under HIPAA?Lee Russell2020-09-08T17:19:06-04:00
A researcher is a covered health care provider if he or she furnishes health care services to individuals, including the subjects of research, and transmits any health information in electronic form in connection with a transaction covered by the Transactions Rule. See 45 CFR 160.102, 160.103.
For example, a researcher who conducts a clinical trial that involves the delivery of routine health care, such as an MRI or liver function test, and transmits health information in electronic form to a third party payer for payment, would be a covered health care provider under the Privacy Rule. Researchers who provide health care to the subjects of research or other individuals would be covered health care providers even if they do not themselves electronically transmit information in connection with a HIPAA transaction, but have other entities, such as a hospital or billing service, conduct such electronic transactions on their behalf. For further assistance in determining covered entity status, see the CMS decision tool.
Do the HIPAA Privacy Rule’s requirements for authorization and the Common Rule’s requirements for informed consent differ?Lee Russell2020-09-08T17:18:38-04:00
Yes. Under the Privacy Rule, a patient’s authorization is for the use and disclosure of protected health information for research purposes. In contrast, an individual’s informed consent, as required by the Common Rule and the Food and Drug Administration’s (FDA) human subjects regulations, is a consent to participate in the research study as a whole, not simply a consent for the research use or disclosure of protected health information. See our research section and frequently asked questions about the research provisions for more informationabout the Common Rule.
For this reason, there are important differences between the Privacy Rule’s requirements for individual authorization, and the Common Rule’s and FDA’s requirements for informed consent. However, the Privacy Rule’s authorization elements are compatible with the Common Rule’s informed consent elements. Thus, both sets of requirements can be met by use of a single, combined form, which is permitted by the Privacy Rule.
For example, the Privacy Rule allows the research authorization to state that the authorization will be valid until the conclusion of the research study, or to state that the authorization will not have an expiration date or event. This is compatible with the Common Rule’s requirement for an explanation of the expected duration of the research subject’s participation in the study. It should be noted that where the Privacy Rule, the Common Rule, and/or FDA’s human subjects regulations are applicable, each of the applicable regulations will need to be followed.
What does the HIPAA Privacy Rule say about a research participant’s right of access to research records or results?Lee Russell2020-09-08T18:40:06-04:00
With few exceptions, the Privacy Rule gives patients the right to inspect and obtain a copy of health information about themselves that is maintained by a covered entity or its business associate in a “designated record set.” A designated record set is basically a group of records which a covered entity uses to make decisions about individuals, and includes a health care provider’s medical records and billing records, and a health plan’s enrollment, payment, claims adjudication, and case or medical management record systems. While it may be unlikely that a researcher would be maintaining a designated record set, any research records or results that are actually maintained by the covered entity as part of a designated record set would be accessible to research participants unless one of the Privacy Rule’s permitted exceptions applies.
One of the permitted exceptions applies to protected health information created or obtained by a covered health care provider/researcher for a clinical trial. The Privacy Rule permits the individual’s access rights in these cases to be suspended while the clinical trial is in progress, provided the research participant agreed to this denial of access when consenting to participate in the clinical trial. In addition, the health care provider/researcher must inform the research participant that the right to access protected health information will be reinstated at the conclusion of the clinical trial.
Does the HIPAA Privacy Rule require a covered entity to create an Institutional Review Board (IRB) or Privacy Board before using or disclosing protected health information for research?Lee Russell2020-09-08T17:17:40-04:00
No. The Institutional Review Board (IRB) or Privacy Board could be created by the covered entity or the recipient researcher, or it could be an independent board.
Is documentation of Institutional Review Boards (IRB) and Privacy Board approval required by the HIPAA Privacy Rule before a covered entity would be permitted to disclose protected health information for research purposes without an individual’s authorization?Lee Russell2020-09-09T00:05:16-04:00
No. Where both the Privacy Rule and the Common Rule apply, both regulations must be followed. The Privacy Rule regulates only the content and conditions of the documentation that covered entities must obtain before using or disclosing protected health information for research purposes.
How does the Rule help Institutional Review Boards (IRB) handle the additional responsibilities imposed by the HIPAA Privacy Rule?Lee Russell2020-09-08T17:09:45-04:00
Recognizing that some institutions may not have Institutional Review Boards (IRBs), or that some IRBs may not have the expertise needed to review research that requires consideration of risks to privacy, the Privacy Rule permits the covered entity to accept documentation of waiver of authorization from an alternative body called a Privacy Board–which could have fewer members, and members with different expertise than IRBs. See the fact sheet and frequently asked questions about the research provisions on this web site for more information about Institutional Review and Privacy Boards.
In addition, the Rule allows an IRB to use expedited review procedures as permitted by the Common Rule to review and approve requests for waiver of authorizations. Similarly, the Rule permits Privacy Boards to use an expedited review process when the research involves no more than a minimal privacy risk to the individuals. An expedited review process permits covered entities to accept documentation of waiver of authorization when only one or more members of the IRB or Privacy Board have conducted the review.
Does the HIPAA Privacy Rule permit the creation of a database for research purposes through an Institutional Review Board (IRB) or Privacy Board waiver of individual authorization?Lee Russell2020-09-08T17:09:20-04:00
Yes. A covered entity may use or disclose protected health information without individuals’ authorizations for the creation of a research database, provided the covered entity obtains documentation that an IRB or Privacy Board has determined that the specified waiver criteria were satisfied. Protected health information maintained by a covered entity in such a research database could be used or disclosed for future research studies as permitted by the Privacy Rule – that is, for future studies in which individual authorization has been obtained or where the Rule would permit research without an authorization, such as pursuant to an IRB or Privacy Board waiver.
Does the HIPAA Privacy Rule prohibit researchers from conditioning participation in a clinical trial on an authorization to use/disclose existing protected health information?Lee Russell2020-09-08T17:08:56-04:00
No. The Privacy Rule does not address conditions for enrollment in a research study. Therefore, the Privacy Rule in no way prohibits researchers from conditioning enrollment in a research study on the execution of an authorization for the use of pre-existing health information.
Are some of the criteria so subjective that inconsistent determinations may be made by Institutional Review Boards (IRB) and Privacy Boards reviewing similar or identical research projects?Lee Russell2020-09-09T00:05:16-04:00
Under the HIPAA Privacy Rule, Institutional Review Boards (IRBs) and Privacy Boards need to use their judgment as to whether the waiver criteria have been satisfied. Several of the waiver criteria are closely modeled on the Common Rule’s criteria for the waiver of informed consent and for the approval of a research study. Thus, it is anticipated that IRBs already have experience in making the necessarily subjective assessments of risks.
While IRBs or Privacy Boards may reach different determinations, the assessment of the waiver criteria through this deliberative process is a crucial element in the current system of safeguarding research participants’ privacy. The entire system of local IRBs is, in fact, predicated on a deliberative process that permits local IRB autonomy. The Privacy Rule builds upon this principle; it does not change it. Nonetheless, the Department will consider issuing guidance as necessary and appropriate to address concerns that may arise during implementation of these provisions.
Will the HIPAA Privacy Rule hinder medical research by making doctors and others less willing and/or able to share with researchers information about individual patients?Lee Russell2020-09-08T17:07:56-04:00
We do not believe that the Privacy Rule will hinder medical research. Indeed, patients and health plan members should be more willing to authorize disclosures of their information for research and to participate in research when they know their information is protected. For example, in genetic studies conducted at the National Institutes of Health, nearly 32 percent of eligible people offered a test for breast cancer risk declined to take it. The overwhelming majority of those who refuse cite concerns about health insurance discrimination and loss of privacy as the reason. The Privacy Rule both permits important research and, at the same time, encourages patients to participate in research by providing much needed assurances about the privacy of their health information.
The Privacy Rule will require some covered health care providers and health plans to change their current practices related to documenting research uses and disclosures. It is possible that some covered health care providers and health plans may conclude that the Rule’s requirements for research uses and disclosures are too burdensome and will choose to limit researchers’ access to protected health information. We believe few providers will take this route, however, because the Common Rule includes similar, and more rigorous requirements, that have not impaired the willingness of researchers to undertake Federally-funded research. For example, unlike the Privacy Rule, the Common Rule requires an Institutional Review Board (IRB) review for all research proposals under its purview, even if informed consent is to be sought. The Privacy Rule requires documentation of IRB or Privacy Board approval only if patient authorization for the use or disclosure of protected health information for research purposes is to be altered or waived.
When is an authorization required from the patient before a provider or health plan engages in marketing to that individual?Lee Russell2020-09-09T00:05:16-04:00