Privacy Policies

UW Medicine has established a comprehensive Privacy Program to be in compliance with 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 Privacy Policies, listed below.

Additionally, several committees have been formed to maintain the Privacy Program at UW Medicine, and 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.

Use & Disclosure Decision Tree

The Privacy Program has developed a decision tree to assist you in quickly determining how and when PHI may be used or disclosed.

Use & Disclosure Decision Tree -

Policy #	Policy/Attachment Title [Revised Date]	Download PDF Here
	Privacy Policies Summary
PP-00	Glossary of Terms
PP-01	Use & Disclosure of Protected Health Information – Organizational Requirements [1/23/09]
PP-01 Attachment	Attachment A: University of Washington HIPAA Designation [1/23/09]
PP-02	Use of Consents, Authorizations or Other Legal Permission from the Patient during Transition to HIPAA Compliance [5/22/06]
PP-03	Administrative Requirements of UW Medicine's Privacy Program [5/21/07]
PP-04	Privacy, Confidentiality, & Information Security Training [10/23/06]
PP-04 Attachments	Attachment A: Privacy, Confidentiality, and Information Security Agreement [10/23/06] Attachment B: UW Medicine HIPAA Temporary Workforce Member/Student Self Study [5/08/08] Attachment C: HIPAA Training Certification Form [5/08/08] Attachment D: Observational Agreement [11/24/08]
PP-05	Complaints and Investigations Related to UW Medicine Privacy Practices [9/28/07]
PP-05 Attachments	Attachment A: Acknowledgment Letter [5/22/06] Attachment B: Resolution Letter [5/22/06]
PP-06	Sanctions for the Failure to Follow Applicable Privacy and/or Information Security Policy or for a Breach of Patient Confidentiality or Information Security [1/25/08]
PP-07	Use and Disclosure of Protected Health Information to Carry Out Treatment, Payment, and Health Care Operations [3/28/08]
PP-08	Use & Disclosure of Protected Health Information Requiring Authorization [10/25/07]
PP-08 Attachments	Attachment A: Authorization to Disclose/Release Protected Health Information Form UH0626 [1/2008] Attachment B: Authorization for UW Medicine to Obtain Protected Health Information Form UH0296 [1/2008] Attachment C: Prohibition on Redisclosure [6/1/07] Attachment D: Oral Redisclosure Form UH 1866 [1/2008] Attachment E: Example Letter for Incomplete Request [2/28/06] Attachment G: Authorization to Use or Disclose Photography/Video Tape Form UH0324 [1/2008] Attachment H: Release of Information Coordination and Action Form [11/02/07] Attachment I: Authorization for UW Medicine to Use or Disclose Protected Health Information for Publicity Form UH1874 [1/2008] Attachment J: UW Medicine Authorization to Disclose Protected Health Information [10/16/07]
PP-09	Use & Disclosure of Protected Health Information for Marketing Communications [5/22/06]
PP-10	Use & Disclosure of Protected Health Information For Fundraising [5/21/07]
PP-11	Verifying the Identity & Authority of Individuals Requesting Access to and Disclosure of Protected Health Information [5/22/06]
PP-12	Use & Disclosure of Protected Health Information by Business Associates [1/22/07]
PP-12 Attachments	Attachment A: UW Medicine Business Associate Agreement [8/10/07] Attachment B: Healthcare Components Business Associate Agreement [1/22/07]
PP-13	Use & Disclosure of Protected Health Information Related to Inpatient Facility Directories & for Disaster Relief Purposes [6/22/07]
PP-13 Attachments	Attachment A: Inpatient Facility Directory Form UH1868 [1/2006]
PP-14	Use & Disclosure of Protected Health Information – Personal Representatives/Surrogate Decision-Makers [7/27/06]
PP-15	Use & Disclosure of Protected Health Information for Involvement in Individual's Care and Notification [10/23/08]
PP-15 Attachments	Attachment A: Prohibition on Redisclosure
PP-16A	Use & Disclosure of Protected Health Information (PHI) Permitted for Public Health Activities [8/3/06]
PP-16B	Use & Disclosure of Protected Health Information (PHI) Permitted for Employers [9/28/06]
PP-16C	Use & Disclosure of Protected Health Information (PHI) Permitted for Health Oversight Activities [10/12/06]
PP-16D	Use & Disclosure of Protected Health Information (PHI) Permitted for Decedents [10/26/06]
PP-16E	Use & Disclosure of Protected Health Information (PHI) Permitted to Avert a Serious Threat to Health or Safety [12/14/06]
PP-16F	Use & Disclosure of Protected Health Information (PHI) Permitted for Specialized Government Functions [5/21/07]
PP-16G	Use & Disclosure of Protected Health Information (PHI) Permitted for Judicial and Administrative Proceedings [1/23/09]
PP-16G Attachments	Attachment A: Subpoena Unenforceable letter template [1/23/09] Attachment B: Subpoena Rejection letter template [1/23/09] Attachment C: Rejection Letter, Out of State Subpoena [1/23/09]
PP-16H	Use & Disclosure of Protected Health Information (PHI) Permitted for Law Enforcement Purposes [6/22/07]
PP-16I	Use & Disclosure of Protected Health Information (PHI) Permitted for Victims of Abuse, Neglect or Domestic Violence [12/14/06]
PP-17	Psychotherapy Notes Management [12/14/06]
PP-18	Use & Disclosure of Protected Health Information for Research [8/22/05]
PP-19	Protected Health Information, Limited Data Set, and De-Identification of Protected Health Information [12/04/07]
PP-19 Attachments	Attachment A: Data Use Agreement for Limited Data Set (for individuals or entities NOT part of UW Medicine workforce) [2/15/06] Attachment B: Data Use Agreement for Limited Data Set for UW Medicine workforce [2/15/06]
PP-19A	Handling Public Records Requests That Contain Protected Health Information [1/23/09]
PP-20	Minimum Necessary Requirements for Use & Disclosure of Protected Health Information [9/28/07]
PP-20A	Access Guide [1/23/09]
PP-20A Attachments	Attachment A: Agreement for Electronic Access to Protected Health Information [1/23/09] Attachment B: Privacy, Confidentiality and Information Security Agreement Pursuant to an Agreement for Electronic Access to PHI [1/25/08] Attachment C: Document IT Systems' Access for a Member of the Workforce [1/25/08] Attachment D: U-Link Program Account Enrollment and Agreement Form [1/23/09] Guide: UW Medicine Quick Reference Guide: Access to Electronic Medical Records for non-UW Medicine Workforce for External Audits/Reviews [5/08/09]
PP-21	Notice of Privacy Practices [1/25/08]
PP-21 Attachments	Attachment A: Joint Notice of Privacy Practices of UW Medicine and Certain Other Providers [1/23/09] Attachment B: Care Agreement Form UH0051 [7/2007] Attachment C: Notice of Privacy Practices Acknowledgment Form UH2045 [8/2006] Attachment D: Financial Agreement Form UH1865 [6/2008] Attachment E: Fundraising Authorization Form UH1867 [1/2006]
PP-22	Rights to Request Additional Privacy Protection for Protected Health Information [2/15/06]
PP-22 Attachments	Attachment A: Request to Consider Additional Privacy Protection for Protected Health Information [1/2006] Attachment B: Standard Response Letter for Restriction [2/15/06] [doc]
PP-23	Individual's Access to Their Protected Health Information and Designated Record Set [2/15/06]
PP-23 Attachments	Attachment A: Patient Access for Access to Protected Health Information Form UH1870 [1/2006] Attachment B: Unreviewable Grounds for Denial example letter [2/15/06] Attachment C: Incomplete Request example letter [2/15/06] Attachment D: Reviewable Grounds for Denial example letter (whole) [2/15/06] Attachment E: Reviewable Grounds for Denial example letter (partial) [2/15/06]
PP-24	Amendment of Protected Health Information/Designated Record Set [7/25/08]
PP-24 Attachments	Attachment A: Amendment Request UH2078 [6/2008] Attachment B: Amendment Request Acknowledgement [7/25/08] Attachment C: Amendment Acceptance example letter [7/25/08] Attachment D: Amendment Request Denial [7/25/08] Attachment E: Medical Record Amendments [7/25/08]
PP-25	Accounting of Disclosures of Protected Health Information [5/22/08]
PP-25 Attachments	Attachment A: Accounting of Disclosures Acknowledgment example letter [2/28/08] Attachment B: Accounting of Disclosures cover letter [2/28/08]
PP-26	Definition of a Designated Record Set [1/11/07]
PP-27	Use and Management of Social Security Numbers [5/23/08]
PP-28	Faxing Protected Health Information [9/28/07]
PP-28 Attachments	Attachment A: Faxing Protected Health Information - facsimile cover sheet [11/09/07]