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Advocating for people with intellectual, developmental, and other disabilities to lead full and equitable lives.
AHRC New York City

Advocating for people with intellectual, developmental, and other disabilities to lead full and equitable lives.

Section 4.04: Interoffice Communication of the Confidential Information of People Supported

Section: 4.04
Issued: 07.02.2014
Revised: 03.20.2023

Purpose:

The purpose of this policy is to provide guidance as to how to handle confidential interoffice communications at AHRC NYC.

Overview:

This policy specifies the special procedures that must be followed when one AHRC NYC employee shares “private health information” (PHI) about a person we support with another AHRC NYC staff person. “Private health information” or confidential information about the people we support must be handled in accordance with HIPAA requirements.

First Choice for Interoffice Sharing of PHI:

When one AHRC NYC staff person needs to send a person’s protected health information to another AHRC NYC staff person, it is best to use the agency’s email system. Documents should be scanned in. Do not include the person’s name in the subject line in the email, rather, use their initials.

Use of Red Envelopes:

When AHRC NYC staff must send an original signed document containing PHI to another staff person, the “Red Envelope Procedure” described below must be followed.

Red Envelope Procedure for Interoffice Sharing of PHI:

  • The name of the staff person to whom the red envelope is being sent must be listed on the envelope as well as the department in which they work.
  • At the time the staff person sends the red envelope, they must send an email to the staff person to whom it is being sent notifying them to expect the red envelope via interoffice mail. A brief summary of the contents should be included in the email.
  • When the staff person receives the red envelope, they must send an email to the staff person who sent it confirming that it arrived.
  • If a staff person mistakenly receives a red envelope not intended for them, the staff person must notify the staff person to whom the envelope should have gone as well as the staff person who sent the envelope and must re-send the envelope to the staff person to whom it was directed. If the staff person who mistakenly received the envelope is unable to determine who sent the envelope or who was supposed to receive it, they must notify the AHRC NYC privacy officer. The privacy officer will determine if a breach needs to be reported.

Procedure When a Red Envelope Is Lost:

When a red envelope is lost in transit, the AHRC NYC privacy officer must be notified as soon as it has been established that it is missing.

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