Notice of Privacy Practices for Protected Health Information

45 CFR 164.520

Background
The HIPAA Privacy Rule gives individuals a fundamental new right to be informed of the privacy
practices of their health plans and of most of their health care providers, as well as to be
informed of their privacy rights with respect to their personal health information. Health plans
and covered health care providers are required to develop and distribute a notice that provides
a clear explanation of these rights and practices. The notice is intended to focus individuals on
privacy issues and concerns, and to prompt them to have discussions with their health plans
and health care providers and exercise their rights.

How the Rule Works

General Rule. The Privacy Rule provides that an individual has a right to adequate notice of
how a covered entity may use and disclose protected health information about the individual, as
well as his or her rights and the covered entity’s obligations with respect to that information.
Most covered entities must develop and provide individuals with this notice of their privacy
practices. The Privacy Rule does not require the following covered entities to develop a notice:

● Health care clearinghouses, if the only protected health information they create or
receive is as a business associate of another covered entity. See 45 CFR 164.500(b)(1).
● A correctional institution that is a covered entity (e.g., that has a covered health care
provider component).
● A group health plan that provides benefits only through one or more contracts of
insurance with health insurance issuers or HMOs, and that does not create or receive
protected health information other than summary health information or enrollment or
disenrollment information. See 45 CFR 164.520(a).

Content of the Notice. Covered entities are required to provide a notice in plain language that
describes:
● How the covered entity may use and disclose protected health information about an
individual.
● The individual’s rights with respect to the information and how the individual may
exercise these rights, including how the individual may complain to the covered entity.
● The covered entity’s legal duties with respect to the information, including a statement
that the covered entity is required by law to maintain the privacy of protected health
information.

● Whom individuals can contact for further information about the covered entity’s privacy
policies.
The notice must include an effective date. See 45 CFR 164.520(b) for the specific requirements for developing the content of the notice. A covered entity is required to promptly revise and distribute its notice whenever it makes material changes to any of its privacy practices.

See 45 CFR 164.520(b)(3), 164.520(c)(1)(i)(C) for health plans, and 164.520(c)(2)(iv) for covered health
care providers with direct treatment relationships with individuals.

Providing the Notice.
● A covered entity must make its notice available to any person who asks for it.
● A covered entity must prominently post and make available its notice on any web site it
maintains that provides information about its customer services or benefits.
● Health Plans must also:
○ Provide the notice to individuals then covered by the plan no later than April 14,
2003 (April 14, 2004, for small health plans) and to new enrollees at the time of
enrollment.
○ Provide a revised notice to individuals then covered by the plan within 60 days of
a material revision.
○ Notify individuals then covered by the plan of the availability of and how to obtain
the notice at least once every three years.
● Covered Direct Treatment Providers must also:
○ Provide the notice to the individual no later than the date of first service delivery
(after the April 14, 2003 compliance date of the Privacy Rule) and, except in an
emergency treatment situation, make a good faith effort to obtain the individual’s written acknowledgment of receipt of the notice.

If an acknowledgment cannot be obtained, the provider must document his or her efforts to obtain the acknowledgment and the reason why it was not obtained.
○ When first service delivery to an individual is provided over the Internet, through
e-mail, or otherwise electronically, the provider must send an electronic notice
automatically and contemporaneously in response to the individual’s first request
for service. The provider must make a good faith effort to obtain a return receipt
or other transmission from the individual in response to receiving the notice.
○ In an emergency treatment situation, provide the notice as soon as it is
reasonably practicable to do so after the emergency situation has ended. In
these situations, providers are not required to make a good faith effort to obtain a
written acknowledgment from individuals.
○ Make the latest notice (i.e., the one that reflects any changes in privacy policies)
available at the provider’s office or facility for individuals to request to take with
them, and post it in a clear and prominent location at the facility.

● A covered entity may e-mail the notice to an individual if the individual agrees to receive
an electronic notice. See 45 CFR 164.520(c) for the specific requirements for providing
the notice.

Organizational Options.
● Any covered entity, including a hybrid entity or an affiliated covered entity, may choose to
develop more than one notice, such as when an entity performs different types of
covered functions (i.e., the functions that make it a health plan, a health care provider, or
a health care clearinghouse) and there are variations in its privacy practices among
these covered functions. Covered entities are encouraged to provide individuals with the
most specific notice possible.
● Covered entities that participate in an organized health care arrangement may choose to
produce a single, joint notice if certain requirements are met. For example, the joint
notice must describe the covered entities and the service delivery sites to which it
applies. If any one of the participating covered entities provides the joint notice to an
individual, the notice distribution requirement with respect to that individual is met for all
of the covered entities. See 45 CFR 164.520(d).