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Revision 22-3; Effective Nov. 8, 2022
All contracting agencies must comply with the U.S. Health Insurance Portability and Accountability Act of 1996 (HIPPA) established standards for protection of client privacy.
Contractors must ensure that all employees and volunteers receive training about client confidentiality during orientation and be made aware that violation of the law regarding confidentiality may result in civil damages and criminal penalties. All employees, volunteers, sub-contractors, and board members or advisory board members must sign a confidentiality statement during orientation.
The client’s preferred method of follow-up to clinic services (cell phone, email, work phone, or text) and preferred language must be documented in the client’s record.
Each client must receive verbal assurance of confidentiality and an explanation of what confidentiality means (kept private and not shared without permission) and any applicable exceptions such as abuse reporting.
3310 Minors and Confidentiality
Revision 22-3; Effective Nov. 8, 2022
Except as permitted by law, a provider is legally required to maintain the confidentiality of care provided to a minor. Confidential care does not apply when the law requires parental notification or consent, or when the law requires the provider to report health information such as in the cases of contagious disease or abuse. The definition of privacy is the ability of the individual to maintain information in a protected way. Confidentiality in health care is the obligation of the health care provider not to disclose protected information. While confidentiality is implicit in maintaining a patient's privacy, confidentiality between provider and patient is not an absolute right.
The HIPAA privacy rule requires a covered entity to treat a “personal representative” the same as the individual with respect to uses and disclosures of the individual’s protected health information. In most cases, parents are the personal representatives for their minor children and they can exercise individual rights, such as access to medical records, on behalf of their minor children (Code of Federal Regulations - 45 CFR Section 164.502(g)).
For more information, see Adolescent Health – A Guide for Providers.
Nondiscrimination and Limited English Proficiency (LEP)
As outlined in the HHSC Uniform Terms and Conditions – Grant Version 2.16, HHSC contractors must comply with state and federal antidiscrimination laws, including but not limited to:
- Title VI of the Civil Rights Act of 1964 (42 U.S.C. Section 2000d et seq.)
- Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. Section 794)
- Americans with Disabilities Act of 1990 (42 U.S.C. Section 12101 et seq.)
- Age Discrimination Act of 1975 (42 U.S.C. Section 6101-6107)
- Title IX of the Education Amendments of 1972 (20 U.S.C. Section 1681 et seq.)
- Administrative rules for HHS agencies, as set forth in the Texas Administrative Code (TAC), Title 1, Part 15, Chapter 395 Civil Rights
More information about nondiscrimination laws and regulations can be found at HHSC Civil Rights Office.
3320 Termination of Services
Revision 22-3; Effective Nov. 8, 2022
A qualifying individual must never be denied services due to an inability to pay. Contractors have the right to terminate services to a client if the client is disruptive, unruly, threatening or uncooperative to the extent that the client seriously impairs the contractor’s ability to effectively and safely provide services, or if the client’s behavior jeopardizes his or her own safety, clinic staff or others. An individual has the right to appeal the denial, modification, suspension or termination of services. (See Fair Hearings, in the Epilepsy rules at Title 26, Part 1, Chapter 355). Any policy related to termination of services must be included in the contractor’s policy manual.
3330 Resolution of Complaints
Revision 22-3; Effective Nov. 8, 2022
Contractors must ensure that clients can express concerns about care received and that complaints are handled in a consistent manner. Contractors’ policy and procedure manuals must explain the process clients may follow if they are not satisfied with the care received.
If a client remains unsatisfied with how the complaint was handled, they can appeal to the HHSC Epilepsy Program Office at Epilepsy@hhs.texas.gov, call 512-438-3769, or mail PO Box 149030, Austin TX 78714-9947. Additional information may be needed.
Any client complaint must be documented in the client’s record.
3340 Research (Human Subject Clearance)
Revision 22-3; Effective Nov. 8, 2022
Contractors considering clinical or sociological research using Epilepsy Program-funded clients as subjects must obtain prior approval from their own internal Institutional Review Board (IRB) and HHSC. Contractors should first contact the HHSC Epilepsy Program (Epilepsy@hhs.texas.gov) to initiate a research request. Next, the Epilepsy Program will assist contractors to find the most current version of the appropriate IRB application to complete and submit. The IRB will review the materials and approve or deny the application.
The contractor must have a policy in place that indicates approval will be obtained from the HHSC Epilepsy Program, as well as the IRB, prior to instituting any research activities. The contractor must also ensure that all staff is made aware of this policy through staff training. Documentation of training on this topic must be maintained.