LOS ANGELES COUNTY
DEPARTMENT OF MENTAL HEALTH
  Policy 500.07 Incidental Use of Disclosure
 
  PROCEDURES
  1. A DMH workforce member may make use or disclosure of PHI that is defined as incidental to or a by-product of a use or disclosure permissible under HIPAA and under DMH HIPAA-related policies and procedures under the following circumstances:
     
    1. DMH workforce members must comply with Department policies on Use and Disclosure of PHI and Requests for PHI in compliance with the policy on Minimum Necessary Standards;
       
    2. DMH workforce members must apply reasonable safeguards to limit the incidental use or Disclosure. Such safeguards include, but are not limited to: (a) taking appropriate precautions to avoid being overheard when discussing an individual’s PHI with that individual, his/her family members or other DMH workforce members; (b) avoiding discussing employee benefits issues involving PHI outside of appropriate DMH work areas; and (c) taking appropriate precautions to avoid leaving documents containing PHI out where non-DMH workforce members could view them.
       
  2. The local program/clinic manager must be responsible for training his/her workforce members on Incidental Uses and Disclosures in compliance with the policy and HIPAA.