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Section 1B 
HIPAA Privacy Rule 
Program Components 
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Five HIPAA Program Components 
Individual (Patient) Rights 
“Minimum Necessary” Information Standard 
Procedures for Data Use in Research 
Limits for Marketing and Fundraising Uses 
Business Associates 
Following is a brief overview of five HIPAA program components 
followed by University covered entities: 
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1.  Patient Rights 
To receive a copy of the University’s Notice of Privacy 
To request restrictions* and confidential communications 
of their PHI; 
To inspect and/or receive an electronic copy of their 
healthcare records.  
To request corrections of their healthcare records. 
To obtain an accounting of disclosures (i.e., a list showing 
when and with whom their information has been shared). 
To file a complaint with a healthcare provider or insurer 
and the U.S. Government if the patient believes his or her 
rights have been denied or that PHI is not being protected. 
To receive notice of a breach of their unsecured PHI.  
* The Final Rule requires that a covered entity must agree to a request to 
restrict the disclosure of PHI to his/her health plan for a health care item or 
service for which the patient has paid in full out of pocket, unless otherwise 
required by law. 
HIPAA sets forth the following 
individual rights for patients. 
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2.  Minimum Necessary 
Generally, a patient’s authorization is required for the use or 
disclosure of PH1.  When a use or disclosure of PHI is permitted, via 
patient authorization or otherwise, HIPAA requires that only the 
amount of PHI that is the MINIMUM NECESSARY to accomplish 
the intended purpose be used or disclosed. 
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Disclosures of PHI 
Employees may not otherwise access or disclose PHI unless: 
HIPAA regulations permit use or disclosure of PHI for: 
providing medical treatment 
processing healthcare payments 
conducting healthcare business operations 
public health purposes as required by law 
the patient has given written permission 
it is within the scope of an employee’s job duties 
proper procedures are followed for using data in research 
required or permitted by law 
Note:  the Final Rule now protects the PHI of a deceased individual 
for period of 50 years following the death of that individual. 
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Imagine that you work with patients to help find ways to pay their 
medical bills.  Through your work, you become aware of a family under 
substantial financial hardship.  You believe that kindhearted members of 
the  community would provide help  “If they only  knew” of  these 
circumstances.  In order to tell this story you must get specific written 
authorization  from  the  patients  or  their  legal  representatives  that 
identifies whom you will tell.  In addition, you may communicate only the 
minimum amount of information necessary to describe the need.   
Note:  This type of “outreach” needs to be approved in advance by 
departmental managers and supervisors and must be consistent with 
institutional policy. 
3.  Research Data 
HIPAA regulates how PHI may be obtained and used for 
research.  This is true whether the PHI is completely 
identifiable or partially “de-identified” in a limited data 
A researcher or healthcare provider is not entitled to use PHI in research 
without the appropriate HIPAA documentation, including an 
individual patient authorization or  
an institutionally approved waiver of authorization.  
HIPAA requirements for accessing and using PHI in research  
are explained in the University’s HIPAA and Research page
Even if a researcher gets a signed “Informed Consent Form” 
from a research subject, if she does not also get a signed 
HIPAA  Authorization  form  (or  obtain  a  waiver  of 
authorization from the Institutional Review Board), she may 
not use data she has collected for her research, presentations 
or publications. 
4.  Marketing & Fundraising
 Without first obtaining a patient authorization, the University may not receive payment for the 
use or disclosure of PHI,  nor may the University sell PHI.  
 The University may only use demographic information, including name, address, other contact 
information, age, gender, and date of birth, as well as certain other information about the medical 
treatment of an individual for fundraising purposes. 
 The Notice of Privacy Practices must advise patients of the prohibitions on marketing and the sale 
of PHI and of their right to “opt out” of being contacted for fundraising purposes.  
 Each fundraising solicitation must contain an easy means for patients to “opt out” of receiving 
such communications in the future.   
5.  Business Associates 
enter into a Business Associate Agreement (called a BAA) with the covered entity (the 
use appropriate safeguards to prevent the access, use or disclosure of PHI other than 
as permitted by the contract, or BAA, with the covered entity; 
obtain satisfactory assurances from any subcontractor that appropriate safeguards are 
in place to prevent the access, use or disclosure of PHI entrusted to it; 
notify the covered entity of any breach of unsecured PHI for which the Business 
Associate was responsible upon discovery; 
ensure its employees and/or those of its subcontractors receive HIPAA training; and 
protect PHI to the same degree as a covered entity. 
An outside company or individual is a Business Associate of the 
University when performing functions or providing services involving  
the use or disclosure of PHI maintained by the University.  
Under the Final Rule, a Business Associate is directly liable for compliance  
with HIPAA Privacy and Security requirements and must: 
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