Revision 23-2; Effective Sept. 15, 2023

All contracting agencies must comply with the U.S. Health Insurance Portability and Accountability Act of 1996 (HIPAA)  established standards for protection of client privacy.

Grantees 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, subgrantees, board members and 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 23-2; Effective Sept. 15, 2023

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 use and disclosure 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 (45 Code of Federal Regulations Section 164.502(g)).

For more information, see Adolescent Health – A Guide for Providers.

3320 Nondiscrimination and Limited English Proficiency (LEP)

Revision 23-2; Effective Sept 15, 2023

As outlined in the HHSC Uniform Terms and Conditions – Grant Version 2.16, HHSC grantees must comply with state and federal anti-discrimination laws, including but not limited to:

More information about nondiscrimination laws and regulations can be found on the HHSC Civil Rights Office page.

Grantees that provide direct services to clients must display certain HHS posters related to civil rights. The posters should be displayed in areas where clients and the public can easily see them, such as lobbies, waiting rooms, front reception desks and locations where people apply for and receive HHS services. The following posters are required: 

3330 Termination of Services

Revision 23-2; Effective Sept. 15, 2023

Never deny a qualifying person services due to an inability to pay.

Grantees 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 grantee’s ability to effectively and safely provide services; or
  • if the client’s behavior jeopardizes their own safety, clinic staff or others.  

A person has the right to appeal the denial, modification, suspension or termination of services. See Appeals, in the PHC rules Title 26, Part 1, Chapter 364.

If an aggrieved client requests a hearing, a grantee shall not terminate services to the client until a final decision is rendered by HHSC. 

Any policy related to termination of services must be included in the grantee’s policy manual.

3340 Resolution of Complaints

Revision 23-2; Effective Sept. 15, 2023

Grantees must ensure that clients can express concerns about care received and to further ensure that those complaints are handled in a consistent manner. Grantees’ 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 by email to the HHSC PHC Office, or mail PO Box 149030, Austin Tx 78714-9947. More information may be needed.

If a client requests an appeal or hearing, a grantee shall not terminate services to the client until a final decision is rendered by HHSC. Any client complaint must be documented in the client’s record.

3350 Research (Human Subject Clearance)

Revision 23-2; Effective Sept. 15, 2023

Grantees considering clinical or sociological research using PHC Services Program funded clients as subjects must obtain prior approval from their own internal Institutional Review Board (IRB) and HHSC.

The grantee must have a policy in place that indicates that prior approval will be obtained from the HHSC PHC Program, as well as the IRB, prior to instituting any research activities. The grantee must also ensure that all staff are made aware of this policy through staff training. Documentation of training on this topic must be maintained.