[Code of Federal Regulations]

[Title 42, Volume 4]

[Revised as of October 1, 2006]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR480.132]



[Page 488-489]

 

                         TITLE 42--PUBLIC HEALTH

 

  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 480_ACQUISITION, PROTECTION, AND DISCLOSURE QUALITY IMPROVEMENT 

 

     Subpart B_Utilization and Quality Control Quality Improvement 

                          Organizations (QIOs)

 

Sec.  480.132  Disclosure of information about patients.



    (a) General requirements for disclosure. Except as specified in 

paragraph (b) of this section, a QIO must--

    (1) Disclose patient identified information in its possession to the 

identified patient or the patient's representative if--

    (i) The patient or the patient's representative requests the 

information in writing;

    (ii) The request by a patient's representative includes the 

designation, by the patient, of the representative; and



[[Page 489]]



    (iii) All other patient and practitioner identifiers have been 

removed.

    (2) Seek the advice of the attending practitioner that treated the 

patient regarding the appropriateness of direct disclosure to the 

patient 15 days before the QIO provides the requested information. If 

the attending practitioner states that the released information could 

harm the patient, the QIO must act in accordance with paragraph (c)(2) 

of this section. The QIO must make disclosure to the patient or 

patient's representative within 30 calendar days of receipt of the 

request.

    (b) Exceptions. (1) If the request is in connection with an initial 

denial determination under section 1154(a)(3) of the Act, the QIO--

    (i) Need not seek the advice of the practitioner that treated the 

patient regarding the appropriateness of direct disclosure to the 

patient; and

    (ii) Must provide only the information used to support that 

determination in accordance with the procedures for disclosure of 

information relating to determinations under Sec.  473.24.

    (2) A QIO must disclose information regarding QIO deliberations only 

as specified in Sec.  480.139(a).

    (3) A QIO must disclose quality review study information only as 

specified in Sec.  480.140.

    (c) Manner of disclosure. (1) The QIO must disclose the patient 

information directly to the patient unless knowledge of the information 

could harm the patient.

    (2) If knowledge of the information could harm the patient, the QIO 

must disclose the information to the patient's designated 

representative.

    (3) If the patient is mentally, physically or legally unable to 

designate a representative, the QIO must disclose the information to a 

person whom the QIO determines is responsible for the patient.



The QIO must first attempt to make that determination based on the 

medical record. If the responsible person is not named in the medical 

record, then the QIO may rely on the attending practitioner for the 

information. If the practitioner is unable to provide a name, then the 

QIO must make a determination based on other reliable information.



[50 FR 15359, Apr. 17, 1985; 50 FR 41887, Oct. 16, 1985. Redesignated at 

64 FR 66279, Nov. 24, 1999, as amended at 69 FR 49267, Aug. 11, 2004]