UW Medicine Compliance

UW Medicine Compliance logo

Box: 358049
Seattle, WA 98195-8049
Fax: 206-221-5172

Box: 358049
Seattle, WA 98195-8049
Fax: 206-221-5172
Web: depts.washington.edu/comply/

Privacy Policies

UW Medicine has established a comprehensive Compliance Program related to the HIPAA Privacy Rule [45 CRF Part 160 and 164], RCW 70.02 [the Uniform Health Care Act], and various other federal and state privacy laws. The foundation of that program is the UW Medicine Compliance Policies, listed below.

Additionally, there are several FAQs and tools that can be found on this website to assist management and workforce members to be compliant with the policies.

Decision Trees

UW Medicine Compliance has developed a decision tree to assist you in quickly determining how and when PHI may be used or disclosed.

Use & Disclosure Decision Tree -

UW Medicine Compliance has developed a decision tree to assist you in determining the minimum necessary for disclosing PHI.

Minimum Necessary Disclosure Decision Tree -

Policy # Policy/Attachment Title [Review Date] Download PDF Here
Privacy Policies Summary [08/12/14]
PP-00 Glossary of Terms [07/01/14]
PP-01 Designation of Health Care Components at the University of Washington [07/01/14]
PP-01
Attachment
  • Attachment A: University of Washington HIPAA Designation
    [07/01/14]
PP-02 Use of Consents, Authorizations or Other Legal Permission from the Patient during Transition to HIPAA Compliance [4/12/12]
PP-03 Administrative Requirements of UW Medicine's Privacy Program [05/06/13]
PP-04 Privacy, Confidentiality, & Information Security Training [07/30/13]
PP-04
Attachments
  • Attachment A: Privacy, Confidentiality, and Information Security Agreement [01/30/14]
  • Attachment B: UW Medicine HIPAA Temporary Workforce Member/Student Self Study [07/30/13]
  • Attachment C: HIPAA Training Certification Form [07/30/13]
  • Attachment D: Observational Agreement [05/30/12]
PP-05 Complaints and Incidents Related to Privacy and Information Security [07/30/13]
PP-05
Attachments
PP-06 Corrective Actions for Noncompliance with Privacy and Information Security Policies [05/09/13]
PP-07 Use and Disclosure of Protected Health Information to Carry Out Treatment, Payment, and Health Care Operations [07/01/14]
PP-08 Use & Disclosure of Protected Health Information Requiring Authorization [07/01/14]
PP-08
Attachments
  • Attachment A: Authorization to Disclose/Release Protected Health Information Form UH0626 [07/01/14]
  • Attachment B: No longer in use
  • Attachment C: Prohibition on Redisclosure [6/1/07]
  • Attachment D: Verbal Redisclosure Form UH 1866 [05/30/2012]
  • Attachment E: Example Letter for Incomplete Request [05/30/2012]
  • Attachment F: Patient Authorization to Use & Disclose Protected Health Information for Publication [05/30/2012]
  • Attachment G: Authorization to Use or Disclose Photography/Video Tape Form UH0324 [07/01/2014]
  • Attachment H: Release of Information Coordination and Action Form [07/30/13]
  • Attachment I: Authorization for UW Medicine to Use or Disclose Protected Health Information for Publicity Form UH1874 [07/01/2014]
  • Attachment J: UW Medicine Authorization to Disclose PHI Status Update Letter to Patient [05/30/12]
PP-09 Use & Disclosure of Protected Health Information for Marketing Communications [07/01/14]
PP-10 Use & Disclosure of Protected Health Information For Fundraising [07/01/14]
PP-11 Verifying the Identity & Authority of Individuals Requesting Access to and Disclosure of Protected Health Information [02/9/12]
PP-12 Use & Disclosure of Protected Health Information by Business Associates [07/01/14]
PP-12
Attachments
PP-13 Use & Disclosure of Protected Health Information Related to Inpatient Facility Directories & for Disaster Relief Purposes [07/01/14]
PP-13
Attachments
  • Attachment A: Inpatient Facility Directory Form UH1868 [07/30/13]
PP-14 Access & Disclosure of Protected Health Information to a Minor or Personal Representatives/Surrogate Decision-Makers [07/01/14]
PP-14
Attachments
  • Attachment A: Parent / Guardian eCare Account Request Process [05/06/13]
  • Attachment B: Adult/Proxy eCare Account Request Process [01/29/2013]
  • Attachment C: UW Medicine Parent/Guardian eCare Account Request [01/29/2013]
  • Attachment D: UW Medicine Request for Adult Proxy eCare Access [01/29/2013]
  • Attachment E: Deactivation of eCare Proxy Access [01/29/2013]
PP-15 Use & Disclosure of Protected Health Information for Involvement in Individual's Care and Notification [07/01/14]
PP-16a Use & Disclosure of Protected Health Information Permitted for Public Health Activities [07/01/14] PP 16a
PP-16b Use & Disclosure of Protected Health Information Permitted for Employers [07/01/14] PP 16b
PP-16c Use & Disclosure of Protected Health Information Permitted for Health Oversight Activities [07/01/14] PP 16C
PP-16d Use & Disclosure of Protected Health Information Permitted for Decedents [07/01/14]
PP-16e Use & Disclosure of Protected Health Information Permitted to Avert a Serious Threat to Health or Safety [07/01/14]
PP-16f Use & Disclosure of Protected Health Information Permitted for Correctional Institutions [07/01/14]
PP-16g Use & Disclosure of Protected Health Information Permitted for Judicial and Administrative Proceedings [07/01/14]
PP-16g
Attachments
 
PP-16h Use & Disclosure of Protected Health Information Permitted for Law Enforcement Purposes [07/01/14]
PP-16h
Attachments
  • Attachment A: Law Enforcement Requests Disclosure of Patient Information [07/01/14]
 
PP-16i Disclosure of Protected Health Information for the Reporting of Violent Injuries [07/01/14] PP 16i
PP-16i
Attachments
 
PP 16j Use & Disclosure of Protected Health Information Permitted for Victims of Abuse, Neglect or Domestic Violence [07/01/14]
PP 16k Use & Disclosure of Protected Health Information Permitted for Military & Veteran Activities and Homeland & National Security Activities [07/01/14]
PP 16l Use & Disclosure of Protected Health Information Permitted for Workers Compensation [07/01/14]
PP-17 Psychotherapy Notes Management [07/01/14]
PP-18 Use & Disclosure of Protected Health Information for Research [07/30/13]
PP-19 Protected Health Information, Limited Data Set, and De-Identification of Protected Health Information [07/01/14]
PP-19
Attachments
  • Attachment A: Data Use Agreement for Limited Data Set (for individuals or entities NOT part of UW Medicine workforce) [04/11/13]
  • Attachment B: Data Use Agreement for Limited Data Set for UW Medicine workforce [04/11/13]
 
PP-19a Handling Public Records Requests That Contain Protected Health Information [07/01/14]
PP-20 Minimum Necessary Requirements for Use & Disclosure of Protected Health Information [4/11/13]
PP-20a Access Management [07/30/13]
PP-20a
Attachments
  • Attachment A: Agreement for Electronic Access to Protected Health Information [07/30/13]
  • Attachment B: Privacy, Confidentiality and Information Security Agreement Pursuant to an Agreement for Electronic Access to PHI [6/12/12]
  • Attachment C: Workforce Member Documentation of IT System Access [07/30/13]
  • Attachment D: UW Medicine U-Link Program Account Enrollment and Agreement Form [10/13]
  • Attachment E: Non-UW Medicine Workforce Privacy, Confidentiality and Information Security Agreement [07/30/13]
 
PP-21 Notice of Privacy Practices [03/15/2013]
PP-21
Attachments
  • Attachment A: Joint Notice of Privacy Practices of UW Medicine and Certain Other Providers [05/15/2013]
  • Attachment B: Notice of Privacy Practices Acknowledgment Form UH2045 [07/08/2014]
 
PP-22 Rights to Request Additional Privacy Protection for Protected Health Information [07/01/14]
PP-22
Attachments
  • Attachment A: Request to Consider Additional Privacy Protection for Protected Health Information [07/08/14]
  • Attachment B: No longer in use.
  • Attachment C: Request to Restrict Disclosure of Health Care Items or Services to Health Plans When Patients Self Pay Out-of-Pocket [07/08/14]
  • Attachment D: Additional Privacy Protections, Restrictions and Alternative Communications Coordination and Action Form [07/01/14]
 
PP-23 Patient's Access to Their Protected Health Information and Designated Record Set [07/01/14]
PP-23
Attachments
  • Attachment A: No longer in use
  • Attachment B: Unreviewable Grounds for Denial example letter [02/27/12]
  • Attachment C: Incomplete Request example letter [02/27/12]
  • Attachment D: Reviewable Grounds for Denial example letter (whole) [07/23/13]
  • Attachment E: Reviewable Grounds for Denial example letter (partial) [07/01/14]
 
PP-24 Amendment of Protected Health Information/Designated Record Set [12/18/13]
PP-24
Attachments
 
PP-25 Accounting of Disclosures of Protected Health Information [07/01/14]
PP-25
Attachments
  • Attachment A: Accounting of Disclosures Acknowledgment example letter [06/14/11]
  • Attachment B: Accounting of Disclosures cover letter [06/14/11]
  • Attachment C: Accounting For Disclosure UH3162 [07/03/12]
 
PP-26 Definition of the UW Medicine Designated Record Set [4/11/13] PP 26
PP-28 Faxing Protected Health Information [8/29/14]
PP-28
Attachments
  • Attachment A: Faxing Protected Health Information - facsimile cover sheet [08/29/14]
 
PP-29 Notification of Impermissible Use or Disclosure of PHI [07/01/14]
PP-29
Attachments
 
PP-30 Safeguarding Patient Information [07/30/13] PP30 Safeguarding Patient Information
PP-31 Identity Theft Prevention [07/01/14] PP31 Identity Theft Prevention
   
PP-32 Patient Audio and Images Security Use and Disclosure [7/30/2013] PP32 Patient Audio and Images Security Use and Disclosure
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