Use or Disclosure of Protected Health Information in Media Relations

Statement of Policy

Washington University and its member organizations (collectively, “Washington University or “WU”) are committed to conducting media relations in compliance with all applicable laws, regulations, and WU policies to protect the privacy of Protected Health Information (“PHI”). To strengthen this commitment, WU has adopted this Policy to ensure that the WU Workforce or members who engage in media relations do so in compliance with the HIPAA Privacy Regulations.

Scope of Policy

This Policy applies to all Uses or Disclosures of PHI in media relations, publicity, promotion and advertising.

Policy

1) Media Inquires Regarding Patient Conditions

a) BJC Health Care and its member hospitals maintain various directories of Individuals who are receiving Treatment, collectively referred to as Facility Directories. (See WU HIPAA Policy on Notice of Privacy Practices). These Facility Directories are not managed or maintained by WU. Therefore, WU does not have access to Facility Directories.

b) If a media representative inquires about an Individual by name or by identifying information such as location or address of an accident, WU should refer the media representative to the Office of Public Affairs of the applicable hospital.

2) Media Requests for Patient Interviews, Photographs, Videotapes or Other Images.

a) WU Workforce or members, including physicians, who have been contacted by the media to provide PHI about Individuals to be included in an article must obtain the Individual’s written Media Authorization prior to Disclosing PHI. The Media Authorization Form is attached hereto as Exhibit A. This Authorization must be obtained regardless of whether the media representative is preparing the article or story for distribution within WU (i.e. reporter for The Record) or distribution outside of WU (i.e. reporter from the St. Louis Post-Dispatch).

b) WU must also obtain an Individual’s Media Authorization before photographing or videotaping an Individual for medical education, staff education, promotion or publicity purposes.

Creation Date: November 22, 2002
Effective Date: April 14, 2003
Last Revision Date: January 9, 2003

Exhibit A

Media Authorization for the Use and Disclosure of
Protected Health Information

This form is a part of our effort to protect your rights. If you have any questions or concerns, please talk to the person helping you with the form.

I authorize the use and/or disclosure of my protected health information as described below:

1. I authorize Washington University to disclose to media representatives and/or public affairs staff members protected health information and information about me, my condition or treatment for purposes of publicity, promotion, education or publication in print, broadcast and electronic media. This authorization includes my likeness on photo, videotape and digital media. My authorization applies to the information described below. Only this protected health information may be used and/or disclosed pursuant to this authorization: _____________________________________________________________________
_____________________________________________________________________ _____________________________________________________________________

2. This authorization expires 10 years from the date that I sign this authorization.

3. I understand that once my protected health information is used and/or disclosed pursuant to this authorization, it may be subject to redisclosure by the recipient(s).

4. I understand that I have the right to revoke this authorization at any time. My revocation must be in writing as described in the Notice of Privacy Practices. I am aware that my revocation is not effective to the extent that I have authorized the use and/or disclosure of my protected health information and such use and/or disclosure has been relied upon by authorized recipients.

5. I understand that I do not have to sign this authorization and that my refusal to sign will not affect my abilities to obtain treatment from Washington University nor will it affect my eligibility for benefits.

6. I understand that I have a right to inspect and copy my own protected health information to be used or disclosed in accordance with the Notice of Privacy Practices.

7. I agree that I will receive no financial remuneration for the use of my image or protected health information as described herein.

* * * * *

I certify that I have received a copy of the authorization.

__________________________		___________________
Name of Individual		Date
____________________________
Signature of Individual, Parent or Personal Representative (Parent or legal guardian must sign for anyone under 18 years of age)
__________________________
Name of Personal Representative
__________________________		___________________
Relationship of Personal Representative to Individual		Physician Name (if applicable)
__________________________________		___________________
Individual's Address		Subject
______________________________		___________________
Individual's Phone		Purpose