This document should be signed prior to using individual identifiable health information (e.g., treatment, diagnosis) for purposes of videotaping or filming interviews with patients for public relations purposes.Īuthorization to Use Protected Health Information for Education and Instruction This document should be signed prior to using individual identifiable health information (e.g., treatment, diagnosis) for marketing activities.Īuthorization to Use Protected Health Information for Public Relations and Other Media Purposes This document should be signed prior to using individual identifiable health information (e.g., treatment, diagnosis) for fundraising activities.Īuthorization for USC Marketing Activities To be signed by all recipients of limited data sets.Īuthorization for USC Fundraising Activities Should be signed by investigators accessing USC or non-USC health information for purposes of conducting research on decedents May ONLY be used in connection with USC-held protected health information.ĬERTIFICATION Request for Decedent Protected Health Information Should be signed by USC researchers accessing health information for purposes of subject recruitment or for other purposes preparatory to research. Please see instructions for use for further information.ĬERTIFICATION Request for Protected Health Information for Preparatory Research Activities Any proposed changes to this form must first be approved by the Office of Culture, Ethics and Compliance. Please attach documents to the subject’s informed consent document.
This template has been reviewed and approved by the respective USC IRBs. See USC HIPAA Policy RES-301 for further information about using these forms. Instructions for completing HIPAA authorization form Must be provided to patient no later than first clinical encounter must be posted in conspicuous location at each clinical site *See USC Policy CLIN-200 for further information regarding use of the Notice of Privacy Practices. USC and DHS agreement to coordinate education effortsĮxplains the terms under which USC and Department of Health Services will accept the HIPAA education certification of the other institution. See USC Policy GEN-102 for further information regarding use of the authorization. This authorization form should be used and tailored for other uses and disclosures for which no other specific template document exists. Those specific authorization forms can be found below. USC has developed specific template authorizations for uses/disclosures of health information for (1) research (2), fundraising (3) marketing and (4) special privacy considerations. Questions about these policies should be directed to the USC Office of Culture, Ethics and Compliance at (213) 740-8258 or Also, see Cooperation with Compliance Investigations policy.ĭated February 19, 2003, to university community regarding compliance with HIPAA privacy rule. The policies located on were developed to assist USC faculty and staff in complying with these regulations. Provides useful information regarding students Personally Identifiable Information.Federal regulations, known as the Health Insurance Portability and Accountability Act (HIPAA) privacy law, generally prohibit the use and disclosure of health information without written permission from the patient. Provides useful into to the UCD community - in a nutshell.įorm to use when communicating a HIPAA privacy incident to the Privacy Officer.įor departments to use when walking through their physical space.ĭocument that explains how a Covered Entity may use and disclose health information kept in your medical record. The EU GDPR (effective May 25, 2018) sets a broad definition for personal information and establishes a variety of requirements regarding privacy and the handling of EU residents' Link to the Office of Information Security's GDPR webpage.
GDPR (General Data Protection Regulation) Visually indicates appropriate uses of PHI.Įxplains the differences between unidentified, LDS, and identifiable PHI.Īn agreement when a limited data set is shared, use and protection outlined. You are being asked to allow information about your hospital stay and related treatment of your illness to be used to write what is called a case report. Will help determine if an entity is a BA, as defined under HIPAA 45 CFR 160.103. Health Insurance Portability and Accountability ActĪ contract to ensure that the BAs will appropriately safeguard PHI.
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