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Limited Waiver of HIPAA Sanctions and Penalties during a declared emergency

Written by Farah Amod | Jan 22, 2025 9:40:13 PM

When natural disasters or public health emergencies strike, healthcare providers must often make quick decisions to ensure the safety and well-being of their patients. During such emergencies, strict adherence to every HIPAA regulation may not always be feasible. To address these situations, the U.S. Department of Health and Human Services (HHS) can issue a Limited Waiver of HIPAA Sanctions and Penalties, allowing healthcare providers to focus on delivering care without fear of immediate penalties for certain HIPAA violations.

 

What the HIPAA waiver covers

According to HHS, the limited waiver applies to specific provisions of the HIPAA privacy rule and is only valid in certain circumstances. The waiver is triggered when both of the following conditions are met:

  1. The President declares an emergency or disaster under the Stafford Act or the National Emergencies Act.
  2. The HHS Secretary declares a public health emergency under the Public Health Service Act.

The waiver temporarily suspends penalties for non-compliance with the following HIPAA requirements:

  • Obtaining a patient’s agreement to speak with family members or friends involved in their care.
  • Honoring a patient’s request to opt out of the facility directory.
  • Distributing a Notice of Privacy Practices (NPP).
  • Patient’s right to request privacy restrictions.
  • Patient’s right to request confidential communications.

As HHS notes, the waiver is limited to the emergency period and applies only to hospitals that have implemented their disaster protocols. It typically lasts for up to 72 hours from the time the hospital activates its emergency protocol.

 

Sharing patient information during emergencies

During emergencies, healthcare providers often need to share patient information quickly to coordinate care or notify family members. The HIPAA waiver makes this process easier by temporarily lifting restrictions that would typically require patient consent.

According to HHS, during an emergency, covered entities are permitted to share information to assist with disaster relief efforts. These efforts may involve sharing information with:

  • Public health authorities
  • Emergency management agencies
  • Family members and others involved in the patient’s care

For example, if a hospital is evacuating patients due to a wildfire, it can share patient information with other healthcare facilities to ensure continuity of care without obtaining prior authorization.

 

Skipping privacy paperwork in emergencies

One of the practical benefits of the HIPAA waiver is that it allows hospitals to streamline their intake processes during emergencies. Distributing a Notice of Privacy Practices (NPP) to every patient can be time-consuming, especially during a surge of emergency admissions.

Under the limited waiver, hospitals are not required to distribute the NPP during the emergency period, freeing healthcare providers to focus on treating patients rather than managing administrative tasks.

 

Notifying family members without consent

In emergency situations, patients may be unable to communicate their condition to family members. The HIPAA waiver allows providers to notify family members, friends, or caregivers about a patient’s condition without obtaining prior consent.

As HHS explains, “When necessary to prevent or lessen a serious and imminent threat to the health and safety of a person or the public, covered entities may disclose protected health information without a patient’s authorization.”

For example, if a patient is transported to a hospital in an unconscious state, healthcare providers can contact the patient’s family to inform them of the patient’s condition and location.

 

Practical examples of HIPAA waivers in action

Wildfires in California

In response to the California wildfires, HHS issued a limited HIPAA waiver to help hospitals manage the surge of displaced patients. The waiver allowed hospitals to share patient information with emergency response agencies and neighboring healthcare facilities to coordinate evacuations and care.

 

Hurricane Katrina

During Hurricane Katrina in 2005, healthcare providers used the HIPAA waiver to share patient information with the Federal Emergency Management Agency (FEMA) and other disaster response agencies. This helped reunite displaced individuals with their families and ensured that patients received necessary medical care despite the chaotic circumstances.

 

Limitations of the HIPAA waiver

The HIPAA waiver is not a blanket suspension of all HIPAA requirements. Healthcare providers must still take reasonable steps to safeguard patient information and limit disclosures to the minimum necessary to achieve the intended purpose.

The waiver does not apply to business associates or entities outside of the covered healthcare providers directly involved in patient care. Additionally, once the emergency period ends, providers must return to full HIPAA compliance.

 

Balancing privacy and emergency response

The HIPAA waiver balances protecting patient privacy and enabling effective emergency response. While it temporarily lifts certain requirements, it does not absolve healthcare providers of their responsibility to protect patient information.

Providers should:

  • Use secure communication channels whenever possible.
  • Limit information sharing to necessary details.
  • Document disclosures made under the waiver for future reference.

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FAQs

Does the HIPAA waiver apply to all healthcare providers during an emergency?

No, the waiver only applies to hospitals that have activated their disaster protocols. It does not automatically cover all healthcare providers, such as private practices or clinics, unless specified by HHS.

 

How long does the limited HIPAA waiver remain in effect?

The waiver typically lasts for up to 72 hours from the time the hospital activates its emergency protocol. After this period, standard HIPAA regulations resume, even if the declared emergency continues.

 

Can healthcare providers share patient information with the media during an emergency?

No, the HIPAA waiver does not permit disclosures to the media or the public. Patient information can only be shared with authorized individuals or agencies involved in the emergency response, such as public health authorities or family members.

 

Are business associates covered by the HIPAA waiver?

No, the waiver applies only to covered entities like hospitals. Business associates, such as third-party vendors or IT service providers, must continue to follow all HIPAA requirements, even during an emergency.

 

Does the HIPAA waiver allow providers to share patient information without safeguards?

No, healthcare providers must still take reasonable steps to safeguard patient information during an emergency. The waiver allows for more flexibility in certain scenarios, but patient privacy protections remain in place, and unnecessary disclosures are not permitted.