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CAP Home > CAP Reference Resources and Publications > HIPAA Resources from the CAP > HIPAA Performance Support Tools

HIPAA Resources

Updated November 3, 2003

 

Performance Support Tools

This page contains 12 performance support tools that you may view online, or print and keep available for future reference. Each link will open a separate page, which will remain open. The College has created these resources based on the HIPAA regulations and legal interpretation available from our legal counsel. If you have specific questions about the regulations and how they apply to you, we recommend you contact your own legal counsel for guidance.
Please provide feedback about these documents and other topics regarding HIPAA you would like to see addressed.

Administrative Requirements (PDF, 77 K)
Use this checklist to ensure you/your practice is in compliance with all administrative requirements of the HIPAA Privacy Rule.

Patients' Access to PHI (PDF, 105 K)
With a few exceptions, patients generally should be able to see and obtain copies of their protected health information (e.g., medical record). Use the following decision tree to help determine whether you may release PHI to patients in accordance with the HIPAA Privacy Rule.

Notice of Privacy Practice (PDF, 429 K)
Covered health plans, doctors, and other health care providers must provide a notice to their patients regarding how they may use personal medical information and patients' rights under the HIPAA Privacy Rule. Use the following decision tree to help determine whether you comply with the HIPAA Privacy Rule regarding your Notice of Privacy Practice.

Do You Have Business Associates? (PDF, 118 K)
By law, the HIPAA Privacy Rule applies only to covered entities; however, health care providers and health plans often use the services of a variety of other persons or businesses (business associates) to carry out their health care activities and functions. Use the following decision tree to help determine whether other entities are your Business Associates under the HIPAA Privacy Rule.

Are You A Business Associate? (PDF, 115 K)
By law, the HIPAA Privacy Rule applies only to covered entities; however, health care providers and health plans often use the services of a variety of other persons or businesses (business associates), including other covered entities, to carry out their health care activities and functions. Use the following decision tree to help determine whether you are a Business Associate of another Covered Entity under the HIPAA Privacy Rule.

Requests to Amend PHI (PDF, 128 K)
Under the HIPAA Privacy Rule, an individual has the right to have a covered entity amend protected health information about the individual in a designated record set for as long as the protected health information is maintained in the designated record set. Use the following decision tree to help determine how to respond to a patient's request to amend his/her PHI in accordance with the HIPAA Privacy Rule.

Research Requests (PDF, 114 K)
In the course of conducting research, researchers may obtain, create, use, and/or disclose individually identifiable health information. Under the Privacy Rule, covered entities are permitted to use and disclose protected health information for research with individual authorization, or without individual authorization under limited circumstances set forth in the Privacy Rule. Use the following decision tree to help determine whether you may release information for the purposes of research in accordance with the HIPAA Privacy Rule.

Tissue Sharing Requests (PDF, 111 K)
In the course of conducting research including the use of tissue samples, researchers may obtain, create, use, and/or disclose individually identifiable health information. Under the Privacy Rule, covered entities are permitted to use and disclose protected health information for research with individual authorization, or without individual authorization under limited circumstances set forth in the Privacy Rule. Use the following decision tree to help determine whether you may release tissue samples in accordance with the HIPAA Privacy Rule.

Access to Deceased Patients' PHI (PDF, 157 K)
The HIPAA Privacy Rule allows for the use and disclosure of a deceased patient's protected health information under certain circumstances, particularly as it relates to performing the duties of a coroner or medical examiner as authorized by law. Use the following decision tree to help determine how you may use and disclose PHI regarding deceased individuals in accordance with the HIPAA Privacy Rule.

Minimum Necessary Requirements Checklist (PDF, 88 K)
Use this checklist to ensure you/your practice has complied with the requirement that all covered entities evaluate their practices and enhance safeguards as needed to limit unnecessary or inappropriate access to and disclosure of PHI.

HIPAA and the CAP Laboratory Accreditation Program
If you participate in the CAP Laboratory Accreditation Program, under the regulations the College is considered a business associate of yours. The College has drafted a model agreement you can use, and can be used as a model for other business associate agreements you need to enter into.

HIPAA-Related Definitions (PDF, 105 K)
This document defines many of the terms commonly used in the HIPAA regulations.

The information contained in these resources is intended solely for education and communication purposes and is not intended to constitute medical advice. The CAP expressly disclaims any and all liability for any information included in these resources.

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