TITLE:

NON-RETALIATION

POLICY:
Columbia University Medical Center will refrain from intimidating, threatening, coercing, discriminating against, or taking any other retaliatory action against any employee, patient, or other individual for the exercise of any right under, or for participation in any process permitted or required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

PURPOSE :
Columbia University Medical Center is committed to protecting patient privacy as mandated by city, state, and federal laws and regulations and encourages its employees and affiliates to report actual or suspected violations of confidentiality laws and regulations without fear of retaliation for their reporting.

PROCEDURES:

1. Non-retaliation for exercising rights or participating in processes. Columbia University Medical Center will not retaliate against any employee, patient, or other individual for:


1. exercising any right granted under, or participating in any process established by city, state, or federal confidentiality laws and regulations, including those rights and processes mandated in HIPAA; or



2. filing a complaint about an improper or unauthorized use or disclosure of a patient's Protected Health Information (PHI) with Columbia University Medical Center or with the Secretary of the Department of Health and Human Services; or



3. testifying, assisting, or participating in an investigation, compliance review, proceeding, or hearing related to HIPAA; or



4. opposing in good faith any act or practice made unlawful by city, state, or federal confidentiality laws, regulations, or policy as long as the manner of the opposition is reasonable and does not use or disclose PHI in violation of HIPAA.


2. Open Door Policy. Columbia University Medical Center will maintain an "open door policy" at all levels of management to encourage individuals to report actual or suspected problems and concerns.



3. Duty to report.
1. Any workforce member who observes or becomes aware of or suspects a wrongful use or disclosure of PHI maintained by Columbia University Medical Center is required to report his/her suspicion or the wrongful use or disclosure as soon as possible to his/her supervisor or the HIPAA Privacy Officer.



2. A workforce member who makes a report of a suspected or actual improper use or disclosure in good faith will not be retaliated against for making the report.



4. Definitions

Protected Health Information is information about a patient, including demographic information that may identify a patient, that relates to the patient's past, present or future physical or mental health or condition, related health care services or payment for health care services.

Workforce means employees of, volunteers and trainees at, and other persons affiliated with Columbia University Medical Center whose work is under the direct control of Columbia University Medical Center, regardless of whether they are paid by Columbia University Medical Center.

RESPONSIBILITY:         HIPAA Privacy Officer, Departments