§164.522(a)(1) Standard: Right of an individual to request restriction of uses and disclosures.
(i) A covered entity must permit an individual to request that the covered entity restrict: (A) uses or disclosures of protected health information about the individual to carry out treatment, payment, or health care operations; and (B) disclosures permitted under §164.510(b).
(ii) Except as provided in paragraph (a)(1)(vi) of this section, a covered entity is not required to agree to a restriction.
(iii) A covered entity that agrees to a restriction under paragraph (a)(1)(i) of this section may not use or disclose protected health information in violation of such restriction, except that, if the individual who requested the restriction is in need of emergency treatment and the restricted protected health information is needed to provide the emergency treatment, the covered entity may use the restricted protected health information, or may disclose such information to a health care provider, to provide such treatment to the individual.
(iv) If restricted protected health information is disclosed to a health care provider for emergency treatment under paragraph (a)(1)(iii) of this section, the covered entity must request that such health care provider not further use or disclose the information.
(v) A restriction agreed to by a covered entity under paragraph (a) of this section, is not effective under this subpart to prevent uses or disclosures permitted or required under §§164.502(a)(2)(ii), 164.510(a) or 164.512.
(vi) A covered entity must agree to the request of an individual to restrict disclosure of protected health information about the individual to a health plan if:
(A) The disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law; and
(B) The protected health information pertains solely to a health care item or service for which the individual, or person other than the health plan on behalf of the individual, has paid the covered entity in full.
Audit Inquiry
Does the covered entity have policies and procedures consistent with the established performance criterion to permit an individual to request that the entity restrict uses or disclosures of PHI for treatment, payment, and health care operations, and disclosures permitted pursuant to §164.510(b)?
Obtain and review policies and procedures against the established performance criterion.
Has the covered entity agreed to a restriction? If yes, obtain and review sample of documentation of each request and subsequent agreement to determine if restrictions are given effect.
Obtain and review all requests since September 23, 2013, for restrictions of information disclosed to a health plan in which the item or service has been paid for out of pocket in full. Obtain and review documentation of covered entity responses to determine if restrictions are given effect.