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Title: Section 63.9 - Health care provider and health facility policy and procedures

Effective Date


63.9 Health care provider and health facility policy and procedures. Each health care provider and health facility employing persons or contracting with persons to perform any activity related to such provider's or facility's rendering of health services shall develop and implement policies and procedures to maintain the confidentiality of confidential HIV related information. Such policies and procedures shall assure that such information is disclosed to employees or contractors only when appropriate under this Part. Such policies and procedures shall include:

(a) initial employee education inservice education of employees regarding the legal prohibition against unauthorized disclosure in Public Health Law Article 27-F and provisions of Article 21, Title III. Updates should be provided to all employees in cases of changes to relevant laws or regulations. A list of all employees who have had such training must be maintained by health care providers and health facilities. Health care providers and health facilities contracting with others for services in which HIV-related information may be disclosed to such contractors, must document evidence that such contractors have been informed of the confidentiality and disclosure requirements of this Part;

(b) maintenance of a list of job titles and the specific employee functions within those titles for which employees are authorized to access such information. This list shall describe the limits of such access to information and must be provided to the employees during employee education sessions;

(c) a requirement that only full-time or part-time employees, contractors and medical, nursing or health-related students who have received such education on HIV confidentiality, or can document that they have received such education or training, shall have access to confidential HIV-related information while performing the authorized functions listed under paragraph (2).

(d) protocols for ensuring that records, including records which are stored electronically, are maintained securely and used for the purpose intended;

(e) procedures for handling requests by other parties for confidential HIV-related information;

(f) protocols prohibiting employees/agents/contractors from discriminating against persons having or suspected of having HIV infection; and

(g) review of the policies and procedures on at least an annual basis.


VOLUME A-1a (Title 10)