Privacy >> TUSDM Policy on Notice of Privacy Practices

TUSDM Policy on Notice of Privacy Practices

I. Purpose and Scope: 
  1. Tufts University School of Dental Medicine (TUSDM) must provide individuals with notice of their rights under HIPAA including the uses and disclosures of their protected health information (PHI) and TUSDM’s legal duties with respect to protected health information. This policy governs the development of the TUSDM Notice of Privacy Practices and its distribution to patients.
  2. This policy applies to:
    1. All TUSDM current and prospective patients.
    2. Any member of the TUSDM workforce directly engaged in new patient recruitment, welcome, and registration processes at one of the TUSDM on-campus clinics at One Kneeland Street and at any of the Tufts Dental Facilities (TDF) remote sites.
II. Policy Statement: 
  1. TUSDM, through its Privacy Officer, will develop a Notice of Privacy Practices (NPP) that meets the HIPAA standards for NPP content. TUSDM will prominently post the availability of the NPP and distribute a full copy of the NPP to all patients and request all patients acknowledge receipt of the NPP electronically as part of their individual patient record in axiUm. 
III. Definitions: 
Protected Health Information
IV. General Rules: 
  1. The official, up-to-date TUSDM NPP will be posted to the publically accessible web site and be available for download at: http://dental.tufts.edu/patient-care/privacy-practices-and-patient-rights/
  2. The official, up-to-date TUSDM NPP will be posted at a prominent location on each clinical floor at One Kneeland Street where it is reasonable to expect that TUSDM patients would be able to read it.
  3. The official, up-to-date TUSDM NPP will be posted at a prominent location on each remote TDF sites where it is reasonable to expect that TUSDM patients would be able to read it.
  4. TUSDM will make the NPP available in paper and/or electronic format to any person who requests it. The individual making the request does not have to be a patient of TUSDM.
  5. TUSDM will ensure that every patient (healthcare proxy or healthcare advocate) who will have direct treatment relationship with a TUSDM dental care provider receives the appropriate NPP at the first delivery of services.
    1. The NPP may be distributed by e-mail if the patient agrees to the electronic notice and agreement has not been withdrawn. 
    2. If TUSDM clinic personnel learns that the e-mail transmission has failed, a hard copy will be provided by mail or in person.
  6. TUSDM will establish standard operating procedures to support consistent distribution of the NPP and to capture patient electronic signature of a written Acknowledgement of Receipt of the Notice of Privacy Practices in axiUm, the electronic patient health record.  
  7. Patient treatment may not be conditioned upon the patient’s signature on the Acknowledgement of Receipt of the Notice of Privacy Practices.
  8. TUSDM clinic personnel will make a good faith effort to secure the patient signature. If an individual refuses to take receipt or acknowledge receipt of the NPP, the clinic personnel will document in axiUm why the acknowledgement was not obtained. 
  9. TUSDM will retain all signed Acknowledgement of Receipt of the Notice of Privacy Practices for a minimum (6) years.
     
V. Policy Compliance Monitoring and Enforcement: 
  1. TUSDM will conduct an audit process to ensure the standard operating procedures are followed and to ensure that over time the records of all “active” patients will comply with TUSDM Notice of Privacy Practices Policy. 
  2. The Privacy Officer will monitor policy compliance and recommend revisions to standard operating procedures or workforce training, as appropriate.
VI. Potential Disciplinary Actions and Sanctions: 
  1. Failure to follow standard operating procedures may trigger review for potential disciplinary action under the TUSDM HIPAA Sanctions Policy.
VII. Related Policies, Procedures, Forms: 
Notice of Privacy Practices
VIII. Approval and Review Cycle: 
  1. This policy will be subject to annual review, revision, and approval by the TUSDM Compliance Committee and, in the event of material changes, official adoption by the TUSDM Dean.
  2. If any material changes are made to the NPP, the modified version will be:
    1. reviewed to ensure NPP meets the “plain language” standard; 
    2. publically posted and integrated into the New Patient Welcome Packets within sixty (60) days of the change; 
    3. uploaded as an electronic NPP document in axiUm on both the TUSDM on campus (One Kneeland Street, Boston) and TDF servers (remote facilities); and 
    4. made available to patients in hard copy at the Front Desks of all clinical floors and TDF sites.  
  3. If necessary, signage on clinical floors and at TDF sites will be updated.