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The University of Texas at Dallas

HIPAA Privacy Manual

Section 20: Accounting for Disclosures of PHI

Policy:

In general, individuals shall have the right to receive an accounting of PHI disclosures made by UTD in the six years prior to the request.

UTD is not required to account for any disclosures that occurred prior to the compliance date of April 14, 2003.

UTD must account for disclosures of PHI for occurrences other than Treatment, Payment or health care Operations (TPO). These require an authorization from either the patient or surrogate decision maker. However, referring physicians (physicians requesting consults or specialty procedures) will not require an authorization or accounting of disclosure of PHI. Disclosures for law enforcement purposes or required by statutory law do not need an authorization.

Procedure:

Right to Accounting of Disclosure of PHI

UTD must provide the individual with a written accounting that includes disclosures of PHI that occurred during the six years (or shorter time period if requested) prior to the date of the request. This includes disclosures to and by business associates.

Content Standards for the Accounting of Disclosure of PHI. The accounting for each disclosure must include:

  1. The date of the disclosure;
  2. The name of the entity or person who received the PHI and, if known, the address of such entity or person;
  3. A brief description of the PHI disclosed; and
  4. A brief statement of the purpose of the disclosure that reasonably informs the individual of the basis for the disclosure; or, in lieu of such statement a copy of the individual’s written authorization; or a copy of a written request for a disclosure if any.

If UTD has made multiple disclosures of PHI to the same person or entity for a single purpose, or pursuant to a single authorization, the accounting may, with respect to such multiple disclosures, provide:

  1. The information required above;
  2. The frequency, periodicity, or number of the disclosures made during the accounting period; and
  3. The date of the last such disclosure during the accounting period.

Compliance Standards

UTD must act on the individual’s request for an accounting, no later than 60 days after receipt of such a request, as follows.

  1. Provide the individual with the accounting requested; or
  2. If UTD is unable to provide the accounting within the time required above, UTD may extend the time to provide the accounting by no more than 30 days, provided that:
    • UTD, within the time limit of 60 days, provides the individual with a written statement of the reasons for the delay and the date by which the covered entity will provide the accounting; and
    • UTD may have only one such extension of time for action on a request for an accounting.

UTD must provide the first accounting to an individual in any 12-month period without charge. UTD may impose a reasonable, cost-based fee for each subsequent request for an accounting by the same individual within the 12-month period, provided that UTD informs the individual in advance of the fee and provides the individual with an opportunity to withdraw or modify the request for a subsequent accounting in order to avoid or reduce the fee. The fee schedule for these services is set by the State of Texas. To obtain the fee schedule contact the Medical Records Department (MRD).

Documentation for Accounting of Disclosures

UTD personnel need to account for disclosures of PHI by documenting any such disclosures. MRD or its designee will account for disclosures in the release of information software. All subsidiary medical record holders will account for disclosure in UTD’s designated electronic tracking system. MRD will be responsible for receiving and processing requests for an accounting of disclosures. MRD must document and maintain a copy of the following:

  1. The required information to be included in an accounting of disclosures, as outlined in the earlier section Accounting of Disclosure of PHI.”
  2. The written accounting that is provided to the individual requesting an accounting of disclosures.

Exceptions to the Right of Accounting of Disclosures

In accounting for disclosures of PHI:

UTD must temporarily suspend an individual’s right to receive an accounting of disclosures to a health oversight agency or law enforcement official if such agency or official provides UTD with a written statement that such an accounting to the individual would be reasonably likely to impede the agency's activities. The written statement must specify the time for which such a suspension is required.

  1. If the agency or official suspends an individual’s right to receive an accounting of disclosures and the statement is made orally, UTD must: Document the statement, including the identity of the agency or official making the statement;
  2. Temporarily suspend the individual’s right to an accounting of disclosures subject to the statement; and
  3. Limit the temporary suspension to no longer than 30 days from the date of the oral statement, unless a written statement from the suspending agency or official is submitted during the time period.

UTD is not required t account for the following disclosures:

  1. To carry out TPO;
  2. To individuals requesting their own PHI;
  3. For the facility’s directory or to persons involved in the individual’s care or other notification purposes;
  4. For national security or intelligence purposes;
  5. To correctional institutions or law enforcement officials; or
  6. That occurred prior to the compliance date of April 14, 2003.