The Arc of Monroe County, NYSARC, Inc
AGENCY POLICY: USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION FOR MARKETING ACTIVITIES (POLICY FOR THE ARC FOUNDATION AND DESIGNEES) SCOPE OF POLICY This policy applies to all authorized staff members conducting or approving marketing activities involving the use or disclosure of person served protected health information. Such staff are referred to in this policy as “marketing staff” which will primarily be The Arc Foundation and its designees. This policy also applies to the agency’s Privacy Officer. STATEMENT OF POLICY Our marketing policy permits marketing activities that are sensitive to the needs of our people served and consistent with our mission. The agency will carefully evaluate the agency’s participation in any marketing of our services, as well as any marketing proposed to be undertaken for third parties. Most marketing communications involving the use of protected health information about agency people served cannot be made without first obtaining the person’s written authorization. Proposed marketing activities therefore must be examined to determine whether such an authorization will be required. Proposed marketing activities may only be approved if all applicable requirements for the use and disclosure of information about the person served (as set forth below) have been met. Marketing staff responsible for complying with this policy should be aware that special privacy protections apply to HIV-related information and mental health information. Some activities that are permitted under this policy may not be permitted when using or disclosing these types of information. Marketing staff must comply with Policies and Procedures related to confidentiality of HIV information, psychotherapy notes, and other applicable confidentiality laws, regulations, policies and procedures when using or disclosing, or approving marketing activities involving the use or disclosure of these sensitive types of information for any reason. Marketing staff are expected to be aware of, and abide by the requirements of, those policies. IMPLEMENTATION OF POLICY A.
Marketing Activities Subject To This Policy
Marketing activities generally include all oral or written communications with a person served about a product or service that encourage him/her to purchase or use that product or service. Agency marketing activities often will involve the use or disclosure of protected health information about a person served because the marketing is directed at people served who are currently receiving, or who previously received, services from the agency. Marketing also includes distributing person served protected health information to another organization so that
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The Arc of Monroe County, NYSARC, Inc
that organization may market its own products and services, if the agency receives direct or indirect remuneration for providing the organization with this protected health information. This policy does not generally apply to various activities related to the routine treatment of people served or routine operations of the agency, even if those activities involve the use or disclosure of protected health information to communicate with people served concerning products or services. Examples of activities that do not constitute marketing include: 1. telling people served whether a product or service is provided by the agency; 2. indicating whether a product or service will be covered by insurance; 3. discussing products or services that may further the treatment for a particular person served; 4. describing potentially beneficial products or services in the course of managing or coordinating the treatment for a particular person served; or 5. recommending alternative treatments, therapies, health care providers or settings of care. B.
Marketing Activities That Do Not Require an Authorization from the Person Served
A written authorization from a person served is not required to use and/or disclose his/her protected health information in connection with the following marketing communications made directly to him/her:
C.
Communications that occur face-to-face (including giving the person served a product sample); or
Communications involving a promotional gift of nominal value (including giving a person served pens, calendars, or other merchandise) that generally promotes the agency.
Marketing Activities That Require an Authorization from the Person Served
For all other types of marketing communications, the protected health information of a person served may only be used or disclosed if the person signs a written authorization for the communication. The agency’s standard authorization form for marketing communications is included in the Appendix to this policy. Examples of marketing communications that require written authorization include: Sending a person served a brochure endorsing the use of another organization’s products or services when those products or services are not necessary for that specific person’s course of treatment (for example, a mass mailing to all people served of brochures generally promoting the products and services of a home health agency); and Disclosing protected health information to third parties, in exchange for direct or indirect remuneration, so that such third parties may use the information for their own marketing activities (for example, selling names of people served to pharmaceutical manufacturers for them to use in drug promotions)
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The Arc of Monroe County, NYSARC, Inc
The person’s written authorization is required even if agency staff members intend to use an outside vendor or business associate to make the marketing communication on behalf of the agency. D.
Accounting For Disclosures
Marketing staff should ensure that all disclosures of protected health information in connection with marketing activities are recorded when and as required by the agency’s policy Accounting of Disclosures.
VIOLATIONS The agency’s Privacy Officer has general responsibility for implementation of this policy. Members of our medical staff and agency staff who violate this policy will be subject to disciplinary action up to and including termination of employment or contract with The Arc of Monroe County. Anyone who knows or has reason to believe that another person has violated this policy should report the matter promptly to his or her supervisor or the agency’s Privacy Officer. All reported matters will be investigated, and, where appropriate, steps will be taken to remedy the situation. Where possible, The Arc of Monroe County will make every effort to handle the reported matter confidentially. Any attempt to retaliate against a person for reporting a violation of this policy will itself be considered a violation of this policy that may result in disciplinary action up to and including termination of employment or contract with The Arc of Monroe County.
QUESTIONS If you have questions about this policy, please contact your department supervisor or the agency’s Privacy Officer. It is important that all questions be resolved as soon as possible to ensure protected health information is used and disclosed appropriately. Effective Date: 4/1/03 Revised: 9/15/08
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The Arc of Monroe County, NYSARC, Inc
Authorization form - Marketing Authorization to use and disclose protected health information to communicate about certain products and services Name of person served: __________________________________________________________ USE AND DISCLOSURE COVERED BY THIS AUTHORIZATION A representative of The Arc of Monroe County must answer these questions completely before providing this authorization form to you. Do not sign a blank form. You or your personal representative should read the descriptions below before signing this form. Who will disclose the information? The person(s) or class of persons authorized to disclose the information are described below.
Who will use and/or receive the information? The person(s) or class of persons authorized to use and/or receive the information are described below.
What information will be used or disclosed? The appropriate boxes should be checked below and the descriptions should be in enough detail so that you (or any organization that must disclose information pursuant to this authorization) can understand what information may be used or disclosed. The following information:
What is the purpose of the use or disclosure? Your health information will be used or disclosed by or to the persons specified on this authorization form in order to provide information about the following products or services.
Will the agency receive any direct or indirect remuneration for communicating with you, or assisting others to communicate with you, about these products or services? Yes No When will this authorization expire? The date or event that will trigger the expiration of this authorization should be described below.
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The Arc of Monroe County, NYSARC, Inc
SPECIFIC UNDERSTANDINGS By signing this authorization form, you authorize the use or disclosure of your protected health information as described above. This information may be redisclosed if the recipient(s) described on this form is not required by law to protect the privacy of the information, and such information is no longer protected by federal health information privacy regulations. You have a right to refuse to sign this authorization. Your health care, the payment for your health care, and your health care benefits will not be affected if you do not sign this form. You have a right to receive a copy of this form after you have signed it. If you sign this authorization, you will have the right to revoke it at any time, except to the extent that the agency has already taken action based upon your authorization. To revoke this authorization, please write to the Privacy Officer at the agency..
SIGNATURE I have read this form and all of my questions about this form have been answered. By signing below, I acknowledge that I have read and accept all of the above. ________________________________________________ Printed name of person served or personal representative
__________________ Date
________________________________________________ Signature of person served or personal representative
__________________ Date
_________________________________________________ Description of personal representative’s authority
__________________ Date
Contact information for person signing this form: Address: ______________________________________________________________________ Phone number: _________________________________________________________________ E-mail address: _________________________________________________________________ The person signing the form must receive a copy of this form once signed.
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