HIPAA: Accounting of Disclosures Guidance Document
A disclosure is a release, transfer, access to, or divulging of information outside of OHSU. In general,
patients have the right to know who has received his/her health information for reasons other than
treatment, payment, or health care operations, or disclosures specifically authorized by the patient.
Examples of this are public health activities (reporting vital statistics, communicable diseases,
cancer/tumor registries), reports about victims of abuse, neglect, or domestic violence, releases as a
result of a subpoena, disclosures about decedents to coroners, medical examiners, or funeral directors,
and other disclosures required by law. Under HIPAA, disclosures that are not part of treatment,
payment, and/or operations and that are not authorized by the patient must be tracked. The list below
will provide a clearer picture of which disclosures are subject to the HIPAA accounting requirement
and which disclosures do not need to be tracked.
INCLUDED IN THE ACCOUNTING
The following disclosures must be recorded using the Accounting of Disclosures System (ADS) if protected
health information is disclosed. This list is designed to capture the most common disclosures, but there may be
others that are not listed. If you are unsure whether a disclosure should be tracked, check with your supervisor or
e-mail oips@ohsu.edu.
Disclosure Examples
1. For Public Health Purposes
•
Immunizations
•Infectious/Communicable disease reporting (i.e., HIV,
STD, TB, foodborne)
•Vital Statistics (i.e., birth and death certificates, fetal death,
teen suicides)
•Newborn Screening
•Oregon Death with Dignity (Physician-Assisted Suicide)
•Reports of death for purposes of organ donation
•Poison Control
•Lead Poisoning
•Suspected pesticide poisoning
•Animal bites
2. About victims of abuse, neglect, or domestic violence This includes disclosure to Social Services or a protective service
agency to report:
•Domestic violence and intimate partner violence
•Elder abuse
•Child abuse
•Abuse of mentally ill or developmentally disabled
3. For health oversight activities
•
Audits (e.g., by Center for Medicare & Medicaid Services)
•Inspections (e.g., Dept of Health & Human Services,
Office for Human Research Protections)
•Oversight Reviews (i.e., OMPRO; OR Dept of Health)
4. For judicial or administrative proceedings
•
Court orders
•Subpoenas
5. For law enforcement purposes
•
Reporting of gunshot wounds
6. To Coroners, Medial Examiners, or Funeral Directors About decedents
7. For cadaveric organ, eye or tissue donation and
transplantation purposes Including activities related to Medicare Conditions of
Participation
8. For human-subject research that does not obtain a
subjects authorization
•
Research that receives a waiver of authorization by the
IRB
•Research involving the health information of decedents
Last Revised 7/22/2016 Page 1 of 2
