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Series of Disclosures. If a series of disclosures was made to the same person or organization on the basis of a single authorization form, associates responsible for individual records need only include the information above for the first disclosure made during the accounting period. Individual records associates may then provide the following information to cover the rest of the series:

 Frequency, periodicity, or number of disclosures made in the series, and o EXAMPLE: Disclosures were made every 2 months.

o EXAMPLE: A total of 15 disclosures were made during the accounting period.

 The date of the last disclosure in the series that was made during the accounting period.

Associates responsible for individual records may also use this abbreviated procedure to account for a series of disclosures that was made for a single purpose permitted in public policy.

Disclosures for Certain Research Activities. Abbreviated procedures apply for disclosures of an individual’s protected health information in the course of certain research activities for which:

 The agency’s Privacy Officer has approved (in accordance with agency policy) disclosure of protected health information about individuals enrolled in the study without their written authorization; and

 The research study involves disclosures of protected health information for 50 or more individuals.

The Privacy Officer will maintain a list of such research activities. Associates

responsible for individual records should consult with the Privacy Officer to determine whether the individual’s information has been used or disclosed for one or more of these research activities. If so, associates responsible for the individual records should obtain from the Privacy Officer and include in the individual’s accounting list a properly completed Accountings of Disclosures For Research Activities form for each research activity. If an individual requests further information after reviewing the accounting list provided by the records associates about how to contact the researchers to whom it is likely the individual’s information was disclosed, associates responsible for the

individual records should refer the individual’s request to the agency’s Privacy Officer. Follow-up on Gaps In Information. Associates responsible for individual records should follow-up with agency associates to fill in any gaps in required information. They should also report to the Privacy Officer any significant failure of agency associates to appropriately track disclosures needed to provide accounting lists in accordance with this policy.

D. Exclusion At Government Request

In some cases, a health oversight agency or law enforcement official may request that the agency suspend an individual’s right to receive an accounting of the disclosures

made to that agency or official. The following procedures must be followed before honoring such a request.

Written Request. The agency or official must present to the Arc of Steuben a statement, in writing, that providing the individual with an accounting of disclosures made to the agency or official would be “reasonably likely to impede the agency or official’s activities”. This statement must also specify how long the suspension will be required.

 During the period of suspension, associates responsible for individual records must prepare the accounting list requested by the individual but exclude any disclosures that were made to the agency or official. Do not notify the individual that these disclosures were excluded.

 When the suspension period is over, associates responsible for individual records must include the disclosures made to the agency or official in an accounting for the individual.

Oral Request. If the agency or official asserts that there is insufficient time to prepare a written statement, associates responsible for the record may grant a suspension for 30 days based on the agency or official’s oral representation that suspension is needed for the reasons above (in person or on the telephone).

 An associate responsible for individual records must document that these statements were made by the agency or official in person or on the phone. The associate must also record the identity of the agency or the official.

 After 30 days, the associates responsible for the individual record must include the disclosures made to the agency or official in an accounting for the individual unless the agency or official has provided a written statement seeking further suspension. The agency’s written statement must meet the requirements explained above about why the suspension is necessary and how long it will last.

E. Collection Of Fees

Individuals are entitled to obtain from the agency one free accounting list every 12 months. If an individual requests any additional accounting lists within the same 12 month period, associates responsible for individual records should prepare an estimate of a reasonable fee that will recover the costs of producing those lists. Associates responsible for the individual records must notify the individual of this estimated fee and give the individual an opportunity to decide whether to continue with the request, modify the request to reduce the fee, or withdraw the request. The individual’s permission to

move forward with preparing the list is required any time a fee will be charged to recover the costs of fulfilling the request. Permission may be oral or written so long as the permission is documented in the individual’s records.

F. Documentation

Associates responsible for individual records must maintain the following records to ensure that the agency properly responds to requests for accountings of disclosures. These documents must be maintained by the agency for six years from the date of their creation.

 Completed tracking forms for all disclosures that may possibly need to be included in a future accounting list for the individual;

 Copies of any requests by the individual for accounting lists (which must be in writing and preferably on form Appendix F);

 Copies of any notices to the individual explaining that the agency requires an extension of time to prepare the requested accounting list;

 Copies of any notices to the individual advising that a fee may be charged for providing an accounting list or lists; and

 Copies of any accounting lists provided to the individual. FUNDRAISING ACTIVITIES

PURPOSE

The purpose of this policy is to define the position of the Arc of Steuben in relationship to fundraising.

POLICY

Fundraising activities involving the use or disclosure of individual information may only be conducted after being approved by the Development Director who will ensure that all requirements for the use and disclosure of individual information have been met.

Individual information or lists should not be used or released before this approval has been obtained from the Development Director or designee.

PROCESS