LOS ANGELES COUNTY
DEPARTMENT OF MENTAL HEALTH
  Policy 500.02 Uses and Disclosures of Protected Health Information Not Requiring an Authorization
 
  PROCEDURES
  1. The Los Angeles County Department of Mental Health (DMH) is permitted or required to use or disclose Protected Health Information (PHI) in the following circumstances:
     
    1. Uses and disclosures to the client who is the subject of the information or client's personal representative. (45 CFR 164.502(a)(1)(i) and (g))
       
    2. Uses and disclosures for treatment, payment, or health care operations.
       
      1. For DMH's own treatment, payment, or health care operations (45 CFR 164.506(c)(1));
         
      2. For treatment activities of a health care provider (45 CFR 164.506(c)(2));
         
      3. To another covered entity or a health care provider for the payment activities of the entity that receives the information (45 CFR 164.506(c)(3));
         
      4. To another covered entity for health care operations activities of the entity that receives the information, if both DMH and that entity have or had a relationship with the client and the disclosure is for quality assessment and improvement activities, review of competence or qualification of health care providers, or health care fraud and abuse detection or compliance. (45 CFR 164.506(c)(4) and 164.501)

        e.         Condition the provision of treatment, payment, enrollment in services or eligibility for benefits to an individual on the provision of an authorization. (45 CFR 164.508(b)(4).
         
    3. Disclosures required by the Secretary of the United States Department of Health and Human Services ("the Secretary") to investigate or determine DMH's compliance with the HIPAA Privacy Rule. (45 CFR 164.502(a)(2)(ii))   
       
    4. Disclosures by whistleblowers to a health oversight agency, public health authority, or attorney based on belief of a HIPAA violation. (45 CFR 164.502(j))
       
  2. DMH may use or disclose PHI without the authorization but requiring the client is informed in advance and given an opportunity to agree, prohibit, or restrict to the use or disclosure in the following circumstances:
     
    1. Uses and disclosures for involvement in the client's care and notification purposes. Agreements or objections may be made either orally or in writing and must be documented in the client's chart.
       
      1. Except when an objection is expressed, DMH may disclose to a family member, other relative, a close personal friend, or any other person identified by the client, the PHI directly relevant to such person's involvement with the client's care or payment for client's health care. (45 CFR 164.510(b)(1)(i))
         
      2. Except when an objection is expressed, DMH may use or disclose PHI to notify, or assist in the notification of (including identifying or locating), a family member, a personal representative of the client, or another person responsible for the care of the client of the client's location, general condition, or death (45 CFR 164.510((b)(ii)). Any use or disclosure of PHI for notification purposes shall be in accordance with Section B.1.b.i and ii.
         
      3. If the client is present and has the capacity to make health care decisions, DMH may use or disclose PHI (45 CFR 164.510(b)(2)) if:
         
        1. Client agrees;
        2. Client does not object to the requested disclosure after being given the opportunity to object; or
        3. DMH administrative staff and rendering providers involved in the care of the client reasonably infers, based on the exercise of professional judgment, that the client does not object to the use or disclosure.
           
      4. If the client is deceased, DMH may disclose to a family member or other persons, who were identified by client and involved in the client's care or payment for health care prior to the client's death, PHI that is relevant to such client's involvement. (45 CFR 164.510(b)(5))
         
    2. Uses and disclosures in emergency circumstances and for disaster relief purposes. DMH may use or disclose PHI directly relevant to client's involvement with care or notification purposes without an agreement or objection.
       
      1. If the client is not present, or the opportunity to agree or object to the use and disclosure cannot practicably be provided because of the client's incapacity or an emergency circumstance, DMH may, in the exercise of professional judgment, determine whether the disclosure is in the best interests of the client and, if so, disclose only the PHI that is directly relevant the person's involvement with the client's health care or payment related to the client's health care or needed for notification purposes. (45 CFR 164.510(b)(3))
         
      2. If DMH believes the client cannot meaningfully agree or object to the sharing of the client's information with family, friends, or other persons involved in their care due to his/her current mental state, DMH is allowed to discuss the client's condition or treatment with family members or other persons identified by the client, if DMH believes it would be in the client's best interests. (45 CFR 164.510(b)(3))
         
      3. If DMH believes the client presents a serious and imminent threat of self or others, consistent with applicable law and standards of ethical conduct, DMH is permitted to disclose necessary information about a client to law enforcement, family members of the client, or other persons, to alert those persons whom DMH believes are reasonably able to prevent or lessen the threat. (45 CFR 164.512(j))
         
      4. DMH, in the exercise of professional judgement, may use or disclose PHI to public or private entities authorized by law to assist in disaster relief efforts for the purpose of coordinating with these entities the uses or disclosures. (45 CFR 164.510(b)(4))
         
  3. DMH may use or disclose PHI without the client's authorization or opportunity for the client to agree or object to the use or disclosure in the following circumstances:
     
    1. Uses and disclosures required by law. (45 CFR 164.512(a))
       
      1. DMH may use or disclose PHI to the extent that such use or disclosure is required by, complies with, and is limited to the relevant requirements of the law.
         
      2. DMH must meet the requirements described in Sections C.3, C.5, or C.6 for uses or disclosures required by law.
         
    2. Uses and disclosures for public health activities. (45 CFR 164.512(b))
       
      1.  DMH may use or disclose PHI to a public health authority or other appropriate government authority authorized by law to receive reports of child abuse or neglect. (45 CFR 164.512(b)(ii)
         
      2. DMH, in its professional capacity or within the scope of employment, shall report known or suspected instances of child abuse or neglect in compliance with state law reporting requirements. 
         
    3. Disclosures about victims of abuse, neglect, or domestic violence. (45 CFR 164.512(c))
       
      1. DMH may disclose PHI about a client whom DMH reasonably believes to be a victim of abuse, neglect, or domestic violence to a government authority, including a social services or protective services agency, authorized by law to receive reports of such abuse, neglect, or domestic violence:
         
        1. To the extent the disclosure is required by law and the disclosure complies with and is limited to the relevant requirements of such law;
        2. If the client agrees to the disclosure; or
        3. To the extent the disclosure is expressly authorized by statute or regulation and:
           
          • DMH, in the exercise of professional judgment, believes the disclosure is necessary to prevent serious harm to the client or other potential victims; or
          • If the client is unable to agree because of incapacity, a law enforcement or other public official authorized to receive the report represents that the PHI for which disclosure is sought is not intended to be used against the client and that an immediate enforcement activity that depends upon the disclosure would be materially and adversely affected by waiting until the client is able to agree to the disclosure. 
             
      2. DMH must promptly inform the client that such a report has been or will be made, except if:
         
        1. DMH, in the exercise of professional judgment, believes informing the client would place the client at risk of serious harm; or
        2. DMH would be informing a personal representative, and DMH reasonably believes the personal representative is responsible for the abuse, neglect, or other injury and that informing such person would not be in the best interests of the client as determined by DMH, in the exercise of professional judgment
           
          • DMH, in its professional capacity or within the scope of employment, shall report the known or suspected instance of abuse, neglect, or domestic violence in compliance with the requirements of state reporting law. 
             
    4. Uses and disclosures for health oversight activities. (45 CFR 164.512(d))
       
      1. DMH may disclose PHI to a health oversight agency for oversight activities authorized by law, including audits; civil, administrative, or criminal investigations; inspections; licensure or disciplinary actions; civil, administrative, or criminal proceedings or actions; or other activities necessary for appropriate oversight of:
         
        1. The health care system;
        2. Government benefit programs for which health information is relevant to beneficiary eligibility;
        3. Entities subject to government regulatory programs for which health information is necessary for determining compliance with program standards; or
        4. Entities subject to civil rights laws for which health information is necessary for determining compliance
           
      2. A health oversight activity does not include an investigation or other activity in which the client is the subject of the investigation or activity and such investigation or other activity does not arise out of and is not directly related to:
         
        1. The receipt of health care;
        2. A claim for public benefits related to health; or
        3. Qualification for, or receipt of, public benefits or services when a client's health is integral to the claim for public benefits or services.
           
      3. If a health oversight activity or investigation is conducted in conjunction with an oversight activity or investigation relating to a claim for public benefits not related to health, the joint activity or investigation is considered a health oversight activity for the purposes of Section C.4
         
    5. Disclosures for judicial and administrative proceedings. (45 CFR 164.512(e))
       
      1. DMH may disclose PHI in the course of any judicial or administrative proceeding:
         
        1. In response to an order of a court or administrative tribunal, provided that DMH discloses only the PHI expressly authorized by such order; or
        2. In response to a subpoena*, discovery request or other lawful process, that is not accompanied by an order of a court or administrative tribunal, if
           
          • DMH receives satisfactory assurance, as described in Section C.5.a.iii, from the party seeking the information that reasonable efforts have been made by such party to ensure that the client who is the subject of the PHI that has been requested has been given notice of the request;

            * All requests for client's medical records including subpoenas, must be forwarded to Health Information Management Office for processing. See Policy 501.01.
             
          • DMH receives satisfactory assurance, as described in Section C.5.a.iv, from the party seeking the information that reasonable effort have been made by such party to secure a qualified protective order that meets the requirements of Section C.5.a.v.
             
        3. For the purposes of the first bullet in Section C.5.a.ii, DMH receives satisfactory assurances from a party seeking PHI if DMH receives from such party a written statement and accompanying documentation demonstrating that:
           
          • The party requesting such information has made a good faith attempt to provide written notice to the client (or, if the client's location is unknown, to mail a notice to the client's last known address);
          • The notice included sufficient information about the litigation or proceeding in which the PHI is requested to permit the client to raise an objection to the court or administrative tribunal; and
          • The time for the client to raise objections to the court or administrative tribunal has elapsed, and:
             
            • No objections were filed; or
            • All objections filed by the client have been resolved by the court of the administrative tribunal and the disclosures being sought are consistent with such resolution.
               
        4. For the purposes of the second bullet of Section C.5.a.i, DMH receives satisfactory assurances from a party seeking PHI, if DMH receives from such party a written statement and accompanying documentation demonstrating that:
           
          • The parties to the dispute giving rise to the request for information have agreed to a qualified protective order and have presented it to the court or administrative tribunal with jurisdiction over the dispute; or
          • The party seeking the PHI has requested a qualified protective order from such court or administrative tribunal.
             
        5. For the purposes of Section C.5.a, a qualified protective order means, with respect to PHI requested under Section C.5.a.ii, an order of a court or of an administrative tribunal or a stipulation by the parties to the litigation or administrative proceeding that:
           
          • Prohibits the parties from using or disclosing the PHI for any purpose other than the litigation or proceeding for which such information was requested; and
          • Requires the return to DMH or destruction of the PHI (including all copies made) at the end of the litigation or proceeding.
             
        6. DMH may disclose PHI in response to lawful process described in Section C.5.a.ii without receiving satisfactory assurance under Sections C.5.a.ii, if DMH makes reasonable efforts to provide notice to the client sufficient to meet the requirements of Section C.5.a.iii or to seek a qualified protective order sufficient to meet the requirements of Section C.5.a.v.
           
      2. Section C.5 does not supersede other sections that otherwise permit or restrict uses and disclosures of PHI.
         
    6. Disclosures for law enforcement purposes. (45 CFR 164.512(f))
       
      1. Pursuant to process and as otherwise required by law. DMH may disclose PHI:
         
        1. As required by law including laws that require the reporting of certain types of wounds or other physical injuries, except for laws subject to child abuse or neglect reporting (Section C.2.a) or victims of abuse, neglect, or domestic violence reporting (Section C.3.a.i); or
        2. In compliance with and as limited by the relevant requirements of:
           
          • A court order or court-ordered warrant, or a subpoena or summons issued by a judicial officer;
          • A grand jury subpoena; or
          • An administrative request, including an administrative subpoena or summons, a civil or an authorized investigative demand, or similar process authorized under law, provided that:
             
            • The information sought is relevant and material to a legitimate law enforcement inquiry;
            • The request is specific and limited in scope to the extent reasonably practicable in light of the purpose for which the information is sought; and
            • De-identified information could not reasonably be used.
               
      2. Limited information for identification and location purposes. Except for disclosures required by law as permitted in Section C.6.a, DMH may disclose PHI in response to a law enforcement official's request for such information for the purpose of identifying or locating a suspect, fugitive, material witness, or missing person, provided that:
         
        1. DMH may disclose only the following information:
           
          • Name and address;
          • Date and place of birth;
          • Social security number;
          • ABO blood type and Rh factor;
          • Type of injury;
          • Date and time of treatment;
          • Date and time of death, if applicable; and
          • A description of distinguishing physical characteristics, including height, weight, gender, race, hair and eye color, presence or absence of facial hair (beard or moustache) scars, and tattoos.
             
        2. Except as permitted in Section C.6.b.i, DMH may not disclose for the purposes of identification or location under Section C.6.b any PHI related to the client's DNA or DNA analysis, dental records, or typing, samples or analysis of body fluids or tissues.
           
      3. Victims of a crime. Except for disclosures required by law as permitted described in Section C.6.a, DMH may disclose PHI in response to a law enforcement official's request for such information about a client who is or is suspected to be a victim of a crime, other than disclosures that are subject to Sections C.2 or C.3, if: The client agrees to the disclosure; or DMH is unable to obtain the client's agreement because of incapacity or other emergency circumstance, provided that:
         
        1. The law enforcement official represents that such information is needed to determine whether a violation of law by a person other than the victim has occurred, and such information is not intended to be used against the victim.
        2. The law enforcement official represents that immediate law enforcement activity that depends upon the disclosure would be materially and adversely affected by waiting until the client is able to agree to the disclosure; and
        3. The disclosure is in the best interests of the client as determined by DMH involved in the individual's care, in the exercise of professional judgment.
           
      4. Decedents. DMH may disclose PHI about a client who has died to a law enforcement official for alerting law enforcement of the death of the client if DMH has a suspicion that such death may have resulted from criminal conduct.
         
      5. Crime on premises. DMH may disclose to a law enforcement official PHI that DMH believes in good faith constitutes evidence of criminal conduct that occurred on a DMH premises.
         
      6. Reporting crime in emergencies.
         
        1. If DMH is providing emergency health care in response to a medical emergency, other than an emergency on its own premises, DMH may disclose PHI to a law enforcement official if such disclosure appears necessary to alert law enforcement to:
           
          • The commission and nature of a crime;
          • The location of such crime or of the victim(s) of such crime; and
          • The identity, description, and location of the perpetrator of such crime.
             
        2. If DMH believes that the medical emergency described in Section C.6.f.i is the result of abuse, neglect, or domestic violence of the client in need of emergency health care, Section C.6.f. does not apply and any disclosure to a law enforcement official for law enforcement purposes is subject to Section C.3.
           
    7. Uses and disclosures about decedents. (45 CFR 164.512(g))
       
      1. DMH may disclose PHI to a coroner or medical examiner for identifying a deceased client, determining a cause of death, or other duties as authorized by law.
         
      2. DMH may disclose PHI to funeral directors, consistent with applicable law, as necessary to carry out their duties with respect to the decedent. If necessary for funeral directors to carry out their duties, DMH may disclose the PHI prior to, and in reasonable anticipation of, the client's death.
         
    8. Uses and disclosures for research purposes. (45 CFR 164.512(i))
       
      1. Use or disclosure PHI for research shall be in accordance with DMH Policy No. 500.05, Uses and Disclosures of Protected Health Information for Research. 
         
    9. Uses and disclosures to avert a serious threat to health or safety. (45 CFR 164.512(j))
       
      1. DMH may, consistent with applicable law and standards of ethical conduct, use and disclose PHI, if DMH, in good faith, believes the use and disclosure:
         
        1. Is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public and is to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat; or
        2. Is necessary for law enforcement authorities to identify or apprehend a client:
           
          • Because of a statement by a client admitting participation in a violent crime that DMH reasonably believes may have caused serious physical harm to the victim; or
          • Where it appears from all the circumstances that the client has escaped from a correctional institution or from lawful custody.
             
      2. A use and disclosure pursuant to the first bullet of Section C.9.a.ii may not be made if the information described in the first bullet of Section C.9.a.ii is learned by DMH:
         
        1. In the course of treatment to affect the propensity to commit the criminal conduct that is the basis for the disclosure under the first bullet of Section C.9.a.ii, or counseling or therapy; or 
        2. Through a request by the client to initiate or to be referred for the treatment, counseling, or therapy described in Section C.9.b.i.
           
      3. A disclosure made pursuant to the first bullet of Section C.9.a.ii shall contain only the statement described in the first bullet of Section C.9.a.ii and the PHI described in Section C.6.b.i.
         
      4. DMH is presumed to have made disclosure in good faith pursuant to Section C.9.a if DMH's belief is based upon its actual knowledge or in reliance on a credible representation by a person with apparent knowledge or authority.
         
    10. Uses and disclosures for specialized government functions. (45 CFR 164.512(k))
       
      1. Military and veteran activities
         
        1. DMH may use and disclose the PHI of clients who are Armed Forces personnel for activities deemed necessary by appropriate military command authorities to assure the proper execution of the military mission, if the appropriate military authority has published, by notice in the Federal Register, the following information:
           
          • Appropriate military command authorities; and
          • The purposes for which the PHI may be used or disclosed.
             
        2. DMH may use and disclose PHI of clients who are foreign military personnel to their appropriate foreign military authority for the same purposes for which uses and disclosures are permitted for Armed Forces personnel under the notice published in the Federal Register pursuant to Section C.10.a.i.
           
      2. National security and intelligence activities
         
        1. DMH may disclose PHI to authorized federal officials for the conduct of lawful intelligence, counter-intelligence, and other national security activities authorized by the National Security Act (50 U.S.C. 401, et seq.) and implementing authority (e.g., Executive Order 12333). 
           
      3. Protective services for the President and others
         
        1. DMH may disclose PHI to authorized federal officials for the provision of protective services to the President or other persons or foreign heads of state or other persons, authorized under law, or for the conduct of investigations authorized by 18 U.S.C. 871 and 879. 
           
      4. Correctional institutions and other law enforcement custodial circumstances
         
        1. If client is an inmate or in lawful custody, DMH may disclose client's PHI to the correctional institution or a law enforcement official when the PHI is necessary for the following purpose
           
          • Health care of such clients;
          • Health and safety of such client or other inmates;
          • Health and safety of the officers or employees of others at the correctional institution;
          • Health and safety of such clients and officers or other persons responsible for the transporting of inmates or their transfer from one institution, facility, or setting to another;
          • Law enforcement on the premises of the correctional institution; or
          • Administration and maintenance of the safety, security, and good order of the correctional institution.
             
        2. For the purposes of this section, a client is no longer an inmate when released on parole, probation, supervised release, or otherwise is no longer in lawful custody
           
    11. Disclosures for workers' compensation. (45 CFR 164.512(1)
       
      1. DMH may disclose PHI as authorized by and to the extent necessary to comply with the laws relating to workers' compensation or other similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault.