Opportunities for the Patient to Agree or Object

Use and disclosure for facility directories (e.g., patient locator, ADT sheet, census list)

Covered entities must ask the patient if they want to be listed in the facility directory and inform them about the information that will be listed and to whom it can be disclosed. If the patient agrees, the covered entity can list certain information in the facility directory and can disclose this information to members of the clergy and except for religious affiliation, to other persons who ask for the patient by name. The regulations allow the following information to be listed in our facility directory providing that the patient has not objected or provided restrictions to the information to be disclosed.

• Patient name
• Patient's location in the facility
• Patient's condition described in general terms
• Patient's religious affiliation

Uses and disclosures for involvement in the individual's care and notification purposes

Covered entities may disclose to a family member, other relative, or a close personal friend of the patient, or any other person identified by the patient, the PHI directly relevant to the individual's involvement with the patient's care or payment for that care. However, this general rule applies differently if the patient is present than if the patient is not present.

If the patient is present

If the patient is present and has the capacity to make health care decisions, the individual must be given an opportunity to agree or object to the use or disclosure of their PHI to a family member, other relative, to a friend or any other person. When asking the patient if he/she wishes PHI to be released to someone else, it is best to pose this question to the patient in private.

If the patient is not present

If the patient is not present or, the opportunity to agree or object to the use or disclosure cannot practicably be provided because of the patient's incapacity or an emergency circumstance, the covered entity may exercise professional judgment to determine whether the disclosure is in the best interest of the patient. In these situations, we can disclose only the information that is relevant to the person's involvement with the patient's care.

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