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Privacy Act: [ 09-17-0003] Indian Health Service Medical Staff Credentials and Privileges Records, HHS/IHS/OHP....
<DOC> [2001 Privacy Act] [From the U.S. Government Printing Office via GPO Access] Indian Health Service #..Table of Contents 09-17-0001 Health and Medical Records Systems, HHS/IHS/OHP. 09-17-0002 Indian Health Service Scholarship and Loan Repayment Programs, HHS/IHS/OHP. 09-17-0003 Indian Health Service Staff Credentials and Privileges Records, HHS/IHS/OHP. #..09-17-0001 #....System name: Health and Medical Records Systems, HHS/IHS/OHP. Security classification: None. System location: Indian Health Service (IHS) hospitals, health centers, school health centers, health stations, field clinics, Service Units, IHS Area Offices (Appendix 1), and Regional Federal Records Centers (Appendix 2). Automated records, including Patient Care Component (PCC) records, are stored at the Data Processing Service Center, IHS, located in Albuquerque, New Mexico (Appendix 1). Records may also be located at hospitals and offices of health care providers who are under contract to IHS, including Tribal contractors. A current list of contractor site, including Tribal contractors, is available by writing to the appropriate System Manager (Area or Service Unit Director) at the address shown in Appendix 1. Categories of individuals covered by the system: Individuals, including both IHS beneficiaries and nonbeneficiaries, who are examined/treated on an inpatient and/or outpatient basis by IHS staff and/or contract (including tribal contract) health care providers. Categories of records in the system: 1. Health and medical records containing: Examination, diagnostic and treatment data, proof of IHS eligibility, social data such as name, address, date of birth, Social Security Number, tribe; case records for special programs such as: Dental, social service, mental health, nursing; and laboratory test results. 2. Follow-up registers of individuals with specific health conditions or a particular health status such as: Tumors, communicable diseases, hospital commitment, suspected and confirmed physical child abuse and neglect, immunizations, self-destructive behavior, or handicap. 3. Logs of individuals provided health care by staffs of specific hospital components such as: Surgery, emergency, obstetric delivery, x-ray and laboratory. 4. Operation and/or disease indices for particular hospitals which list each relevant patient by the operation or disease. 5. Monitoring strips and tapes such as fetal monitoring strips and EEG and EKG tapes. 6. Third-party reimbursement records containing name, address, date of birth, date of admission and Medicare or Medicaid claim numbers, SSN, health plan name, insurance number, employment status, and other relevant claim information necessary to process and validate third-party reimbursement claims. Authority for maintenance of the system: Section 321 of the Public Health Service Act, as amended, (42 U.S.C. 248), ``Hospitals, Medical Examinations and Medical Care.'' Section 327A of the Public Health Service Act, as amended, (42 U.S.C. 254a-1), ``Hospital-Affiliated Primary Care Centers.'' Indian Self Determination and Education Assistance Act (25 U.S.C. 450). Snyder Act (25 U.S.C. 13). Indian Health Care Improvement Act (25 U.S.C. 1601 et. seq). Construction of Community Hospitals Act (25 U.S.C. 2005-2005f). Indian Health Service Transfer Act (42 U.S.C. 2001- 2004). Purpose(s): The purposes of this system are: 1. To provide a description of a patient's illness, the treatment administered and results achieved, and to plan for future care of the patient. 2. To provide IHS program officials with statistical data upon which the health care program is evaluated and modified to meet future needs. 3. To serve as a means of communication among members of the health care team who contribute to the patient's care by integrating information from field visits with that from IHS facilities which have provided treatment. 4. To serve as the official documentation of health care rendered. 5. To contribute to continuing education of IHS staff to improve their competency to deliver health care services. 6. For disease surveillance purposes. For example: (a) The Centers for Disease Control may use these records for their monitoring of various communicable diseases among persons residing within the United States; and, (b) The National Institutes of Health may use these records for their review of the prevalence of particular diseases (i.e., malignant neoplasms, diabetes mellitus, arthritis, metabolism and digestive diseases) for various ethnic groups of the Nation. 7. To compile and provide aggregated program statistics. Upon request of other components of the Department, IHS will provide statistical information, from which individual identifiers have been removed, such as: (a) To the National Center for Health Statistics, for its dissemination of aggregated health statistics for various ethnic groups; (b) To the Assistant Secretary for Population Affairs to keep a record of the number of sterilizations provided through the use of Federal funds; (c) To the Health Care Financing Administration for the documentation of IHS health care covered by the Medicare and Medicaid programs for third-party reimbursement; and (d) To the Bureau of Support Services, Health Care Financing Administration, to determine the prevalence of end-stage renal disease among the American Indian and Alaska Native population and to coordinate the care of American Indian and Alaska Native patients with this condition. 8. To process and collect third-party claims. 9. To improve the IHS national patient care database through obtaining and verifying patients' SSNs with the Social Security Administration. Routine uses of records maintained in the system, including categories of users and the purposes of such uses: Note: Special requirements for alcohol and drug abuse patients: If an individual receives treatment, or referral for treatment, for alcohol or drug abuse, then the Confidentiality of Alcohol and Drug Abuse Patient Records Regulations, 42 CFR part 2 may apply. In general under these regulations, the only disclosures of the alcohol or drug abuse record which may be made without patient consent are: (1) To meet medical emergencies (42 CFR Part D, sec. 2.51), (2) for research, audit, evaluation and examination (42 CFR Part D, secs. 2.52 and 2.53), (3) pursuant to a court order (42 CFR 2.61-2.67), and (4) pursuant to a qualified service organization agreement, as defined in 42 CFR 2.11. In all other situations, written consent of the patient is usually required prior to disclosure of alcohol or drug abuse information under the routine uses listed below. Individuals acting in loco parentis to minors, as well as parents, legal guardians, and custodians may act on behalf of the subject individual for purposes of giving consent for disclosures to others when it is determined that the subject individual is a minor who is unable to or cannot exercise with appropriate understanding, the right of consent by himself or herself. 1. Records may be disclosed to State, local or other authorized organizations which provide health services to American Indians and Alaska Natives, or provide third-party reimbursement or fiscal intermediary functions, for the purpose of planning for or providing such services, billing or collecting third-party reimbursements and reporting results of medical examination and treatment. 2. Records may be disclosed to Federal and non-Federal school systems which serve American Indians and Alaska Natives for the purpose of student health maintenance. 3. Records may be disclosed to organizations deemed qualified by the Secretary to carry out quality assessment, medical audits, utilization review or to provide accreditation or certification of health care facilities or programs. 4. Records may be disclosed to authorized organizations, such as the United States Office of Technology Assessment, or individuals for conduct of analytical and evaluation studies sponsored by the IHS. 5. Records may be disclosed to a congressional office in response to an inquiry from that office made at the request of the subject individual. 6. A record may be disclosed for a research purpose, when the Department: (a) Has determined that the use or disclosure does not violate legal or policy limitations under which the record was provided, collected, or obtained; (b) Has determined that the research purpose (1) cannot be reasonably accomplished unless the record is provided in individually identifiable form, and (2) warrants the risk to the privacy of the individual that additional exposure of the record might bring; (c) Has required the recipient to--(1) establish reasonable administrative, technical, and physical safeguards to prevent unauthorized use or disclosure of the record, and (2) remove or destroy the information that identifies the individual at the earliest time at which removal or destruction can be accomplished consistent with the purpose of the research project, unless the recipient has presented adequate justification of a research or health nature for retaining such information, and (3) make no further use or disclosure of the record except--(A) in emergency circumstances affecting the health or safety of any individual, (B) for use in another research project, under these same conditions, and with written authorization of the Department, (C) for disclosure to a properly identified person for the purpose of an audit related to the research project, if information that would enable research subjects to be identified is removed or destroyed at the earliest opportunity consistent with the purpose of the audit, or (D) when required by law; (d) Has secured a written statement attesting to the recipient's understanding of, and willingness to abide by these provisions. 7. The IHS health care providers may disclose information from these records regarding the commission of crimes or the occurrence of communicable diseases, tumors, suspected child abuse, births, deaths, alcohol or drug abuse, etc., as required by Federal law or regulation or State or local law or regulation of the jurisdiction in which the facility is located. Disclosure may be made to organizations as specified by the law or regulation, such as births and deaths to State or local health departments, and crimes to law enforcement agencies. In federally conducted or assisted alcohol or drug abuse programs, the disclosure of the contents of records which pertain to patient identity, diagnosis, prognosis or treatment of alcohol or drug abuse is restricted under 42 CFR part 2; e.g., disclosure of patient information on alcohol and drug abuse for purposes of criminal investigation generally must be authorized by court order issued under 42 CFR 2.65 except that reports of suspected child abuse may be made to the appropriate State or local authorities under State law. 8. The IHS health care providers may disclose information from these records regarding suspected cases of child abuse to: (1) Agencies of any Indian tribe, any State or the Federal Government that need to know the information in the performance of their duties, and (2) members of community child protection teams of the purpose of establishing a diagnosis, formulating a treatment plan, monitoring the plan, investigation reports of suspected child abuse, and making recommendations to the appropriate court. Community child protection teams are comprised of representatives of: Tribes, the Bureau of Indian Affairs, child protection service agencies, the judicial system(s) (local, State and/or tribal, law enforcement agencies and IHS). In federally conducted or assisted alcohol or drug abuse programs, the disclosure to the contents of records which pertain to patient identity, diagnosis, prognosis, or treatment of alcohol or drug abuse is restricted under 42 CFR part 2; e.g., disclosure of patient information on alcohol or drug abuse for purposes of criminal investigation generally must be authorized by court order issued under 42 CFR 2.65 except that reports of suspected child abuse by be made to the appropriate State or local authorities under State law. 9. The Department may disclose information from this system of records to the Department of Justice, to a court or other tribunal, or to another party before such tribunal, when: (a) HHS, or any component thereof; or (b) Any HHS employee in his or her official capacity; or (c) Any HHS employee in his or her individual capacity where the Department of Justice (or HHS, where it is authorized to do so) has agreed to represent the employee; or (d) The United States or any agency thereof where HHS determines that the litigation is likely to affect HHS or any of its components, is a party to litigation or has an interest in such litigation, and HHS determines that the use of such records by the Department of Justice, the tribunal, or the other party is relevant and necessary to the litigation and would help in the effective representation of the governmental party, provided, however, that in each case, HHS determines that such disclosure is compatible with the purpose for which the records were collected. 10. Records may be disclosed to the Bureau of Indian Affairs and its contractors for the identification of American Indian and Alaska Native handicapped children to permit that Bureau to carry out the Education for All Handicapped Children Act of 1975 (20 U.S.C. 1401 et seq.). 11. Records may be disclosed to an IHS contractor, including tribal contractors, for the purpose of computerized data entry or maintenance of records contained in this system. The contractor shall be required to maintain Privacy Act safeguards with respect to the receipt and processing of such records. 12. Records may be disclosed to a health care provider undercontract to IHS (including tribal contractors) to permit the contractor to obtain health and medical information about the subject individual in order to provide appropriate health services to that individual. The contractor shall be required to maintain Privacy Act safeguards with respect to the receipt and processing of such records. 13. Records may be disclosed to the State of Alaska, Department of Health and Social Services (DHSS) (which supplies part or all of this information to IHS), in response to its request for patient summaries, portions of immunization registers, disease indices and other computer-generated medical summaries. This information assists DHSS in its provision of health care to the subject individual. Disclosure to the State of Alaska's DHSS is limited to information concerning its patients. 14. Disclosures regarding specific medical services may be made from the records of a minor patient to the minor's parent or legal guardian who previously consented to those specific medical services. 15. (a) PHS may inform the sexual and/or needle-sharing partner(s) of a subject individual who is infected with the human immunodeficiency virus (HIV) of their exposure to HIV, under the following circumstances: (1) The information has been obtained in the course of clinical activities at PHS facilities carried out by PHS personnel or contractors; (2) The PHS employee or contractor has made reasonable efforts to counsel and encourage the subject individual to provide the information to the individual's sexual or needle-sharing partner(s); (3) The PHS employee or contractor determines that the subject individual is unlikely to provide the information to the sexual or needle-sharing partner(s) or that the provision of such information cannot reasonably be verified; and (4) The notification of the partner(s) is made, whenever possible, by the subject individual's physician or by a professional counselor and shall follow standard counseling practices. (b) PHS may disclose information to State or local public health departments, to assist in the notification of the subject individual's sexual and/or needle-sharing partner(s), or in the verification that the subject individual has, notified such sexual or needle-sharing partner(s). Records may be disclosed to student volunteers, individuals working under a personal services contract, and other individuals performing functions for PHS who do not technically have the status of agency employees, if they need the records in the performance of their agency functions. Policies and practices for storing, retrieving, accessing, retaining, and disposing of records in the system: Storage: File folders, ledgers, card files, microfiche, microfilm, computer tapes, disk packs and automated files. Retrievability:
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