UW Medicine Compliance

Breach Notification – COMP.105


The purpose of this policy is to establish the following:

  • The process UW Medicine follows to investigate potential breaches of protected health information (PHI) and refer potential breaches of non-PHI University Personal Data to the appropriate department;
  • UW Medicine’s obligation to notify patients and other parties of a breach of PHI;
  • The parties that must be notified and timelines that must be observed;
  • Required content of notifications made to patients; and
  • Parties responsible for implementing the policy.


Personal Data:

A. An individual’s first name or first initial and last name in combination with any one or more of the following data elements:

  1. Social Security number;
  2. Driver’s license number or Washington identification card number;
  3. Financial account number (debit, credit, etc.) in combination with any required security code, access code, or password that would permit access to an individual’s financial account, or any other numbers or information that can be used to access a person’s financial account;
  4. Full date of birth;
  5. Private key that is unique to an individual and that is used to authenticate or sign an electronic record;
  6. Student, military, or passport identification number;
  7. Health insurance policy number or health insurance identification number;
  8. Any information about a consumer’s medical history or mental or physical condition or about a health care professional’s medical diagnosis or treatment of the consumer; or
  9. Biometric data generated by automatic measurements of an individual’s biological characteristics such as fingerprint, voiceprint, eye retinas, irises, or other unique biologic patterns or characteristics that is used to identify a specific individual.

B. User name or email address in combination with a password or security questions and answers that would permit access to an online account; and

C. Any of the data elements or any combination of the data elements described in Section A, above, without the consumer’s first name or first initial and last name if:

  1. Encryption, redaction, or other methods have not rendered the data element or combination of the data elements unusable; and
  2. The data element or combination of data elements would enable a person to commit identity theft against a consumer.

D. Personal Data does not include publicly available information that is lawfully made available to the general public from federal, state, or local government records.

Policy PDF

Administrative Information

Applicability: UW Medicine Affiliated Covered Entity

Policy Title: Breach Notification

Policy Number: COMP.105

Superseded Policy: PP-29

Date Established: October 11, 2017

Date Effective: February 19, 2021

Next Review Date: February 19, 2024

Policy Statement

UW Medicine workforce members shall report potential breaches of PHI to UW Medicine Compliance. UW Medicine shall review all relevant facts of a reported event to determine if a breach of PHI has occurred, which may include a formal risk assessment based on required factors to determine the probability that the PHI has been compromised. When a breach is confirmed, UW Medicine shall provide written notification to appropriate parties. The department in which the potential breach occurs shall cooperate with the investigation, assist in remediating identified issues and may be responsible for funding the response and notification of affected patients.

I. Assessment of a Potential Breach Involving PHI

A. UW Medicine reviews all relevant facts of the reported event and determines if the acquisition, access, use or disclosure of PHI:

1. Was not for treatment, payment or healthcare operations;
2. Was not authorized by the patient;
3. Was not otherwise allowed by law.

B. UW Medicine determines if the circumstances meet any of the following breach notification exceptions:

1. An unintentional acquisition, access or use of PHI by a workforce member or business associate who is acting in good faith within the scope of their authority (providing it does not result in further impermissible use or disclosure);
2. An inadvertent disclosure of UW Medicine PHI between two persons who are both authorized to access UW Medicine PHI, providing the information received as a result of such disclosure is not further impermissibly used or disclosed; or
3. A disclosure of PHI to an unauthorized person, who UW Medicine believes, in good faith, would not reasonably have been able to retain such information.

C. UW Medicine may still demonstrate that there is a low probability that the PHI has been compromised by conducting a formal risk assessment based on a minimum of the following factors:

1. The nature and extent of the PHI involved, including the types of identifiers and the likelihood of re-identification;
2. The unauthorized person who used the PHI or to whom the disclosure was made;
3. Whether the PHI was actually acquired or viewed; and
4.  The extent to which the risk to the PHI has been mitigated.

D. If none of the exclusion criteria apply and a low probability of compromise to the PHI cannot be demonstrated, a breach of PHI is confirmed and UW Medicine completes the notification process.

II. Parties Required to be Notified

A. The patient(s).
B. The Secretary of the Department of Health and Human Services (DHHS).
C. The Washington State Attorney General (when a security breach involves more than 500 Washington state residents).
D. The local media (when a privacy breach involves more than 500 residents of any given state or jurisdiction).

III. Notification Timelines

In general, notifications are made as soon as possible, without unreasonable delay and in no case later than 60 calendar days after the breach discovery date.


• Notification may be delayed if it would impede a criminal investigation or cause damage to national security.
• If a breach involves less than 500 patients, the timeframe for notification to DHHS is within 60 days of the end of the calendar year in which the breach occurred.

IV. Required Elements of Patient Notifications

A. Written Notifications

1. Must be sent by UW Medicine Compliance and signed by the UW Medicine Chief Privacy Officer or designee.

2. Must be sent by first-class mail to the patient’s last known address (or to the patient’s personal representative if the patient is deceased and UW Medicine has the personal representative’s address). If specified as a preference by the patient, the notification may be sent by email.

3. Must contain the following elements:

• A brief description of what happened, including the breach discovery date and the actual date of the incident, if known;
• A specific description of the unsecured PHI that was involved in the breach (such as full name, Social Security number, date of birth, home address, account number or disability code);
• The steps patients should take to protect themselves from potential harm resulting from the breach;
• A brief description of what UW Medicine is doing to investigate the breach, mitigate losses and help prevent further breaches; and
• Instructions for obtaining further information, making inquiries and obtaining assistance (including toll-free telephone number, email address, website or postal address).

B. Alternatives to Written Notification

1. If there is insufficient or out-of-date contact information that precludes direct written notification to 10 or more patients, UW Medicine will provide substitute notice. Substitute notice must include a toll-free phone number for obtaining additional information about the breach and may be in one of the following forms:

• A conspicuous posting for 90 days on the UW Medicine website;
• A notice in appropriate print or broadcast media that serve geographic areas where affected patients likely reside;
• An alternative form of written notice, such as by email or by telephone.

2. If imminent misuse of unsecured PHI is suspected, notification may be by telephone or other means.

V. Documentation Requirements

Written documentation must be maintained to demonstrate completion of the following actions:

• Breach risk assessment; and
• Notification to required parties, including copies of letters

VI. Responsibility for Implementation

A. UW Medicine Compliance assesses whether an incident constitutes a breach as defined by the Health Insurance Portability and Accountability Act, makes the relevant recommendation to the UW Medicine Chief Privacy Officer (or designee), makes the required notifications and maintains all documentation.

B. The UW Medicine Chief Privacy Officer (or designee) makes the final breach determination and issues patient notifications.

C. The department in which the breach occurred may be required to pay for the cost of notifying patients.

VII. Breaches Involving Personal Data (non-PHI)

A. Unforeseen events, incidents, and potential or confirmed data breaches of Personal Data that does not constitute PHI must be reported to the department responsible for managing such incidents in accordance with University or entity policy.

B. Communications to persons, other than patients or human subjects, about breaches involving University Personal Data will be made as directed by the University Privacy Officer.

  • Notification in the Case of Breach of Unsecured Protected Health Information, 45 C.F.R. §164, Subpart D.
  • Privacy of Individually Identifiable Health Information, 45 C.F.R. §164, Subpart E.
  • Revised Code of Washington (RCW) 19.255 Personal Information – Notice of Security Breaches.
  • RCW 19.86.090 Civil action for damages —Treble damages authorized — Action by governmental entities.
  • RCW 42.56.590 Personal information — Notice of security breaches.