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Applicants, Mentors and Supervisors, Be Mindful of HIPAA Regulations

APC® Forum September 2015, Vol. 17 No. 6


BCCI has seen a recent increase in HIPAA violations by certification candidates. These are not in any way intentional, but nonetheless, HIPAA is the law and BCCI’s Commission on Certification takes it seriously. Any applicant with a HIPAA violation must wait six months before reapplying for certification. In an effort to decrease the number of violations, please be aware of the following.
First, a requirement with each of the two Chaplain Clinical Contacts is to demonstrate PRO5: Document One’s Contribution of Care Effectively in the Appropriate Records. The Chaplain Clinical Contact cover sheet indicates that the applicant should provide an example of patient record documentation. This certainly may be a print out of an electronic medical record with all of the identifying information removed OR it may simply be the applicant typing out what s/he would have put into the record. BCCI certification interview committees are using this information to determine if the competency is met and the chaplain can effectively use documentation. It is NOT to verify that the Chaplain Clinical Contact is within the needed dates or about an actual patient.
Second, names and birthdates are only two of the 18 identifiers of the individual – or of relatives, employers or household members of the individual – which must not be used in the Chaplain Clinical Contact narrative. It is this list of 18 identifiers that BCCI uses to check for HIPAA violations.

1. Names ( Both first and last)
2. All geographic subdivisions smaller than a state, including a street address, city, county, precinct, zip code  and their equivalent geocodes, except for the initial three digits of a zip code if, according to the current publicly available data from the Bureau of Census, (1) the geographic unit formed by combining all zip codes with the same initial digits contains more than 20,000 people, and ( 2) the initial three digits of a zip code for all such geographic units containing 20,000 or fewer people are changed to 000.
3. All elements of dates ( except year) for dates directly related to an individual, including birth date, admission date, discharge date and date of death; and all ages over 89 and all elements of date ( including year) indicative of such age, except that such ages and elements may be aggregated into a single category of “ age 90 or over”.
4. Telephone numbers
5. Fax numbers
6. E-mail addresses
7. Social Security numbers
8. Medical record numbers
9. Health plan beneficiary numbers
10. Account numbers
11. Certificate/license numbers
12. Vehicle identifiers and serial numbers, including license plate numbers
13. Device identifiers and serial numbers
14. Web Universal Resource Locators
15. Internet Protocol addresses
16. Biometric identifiers, including finger and voice prints
17. Full-face photographic images and any comparable images
18. Any other unique identifying number, characteristic or code (This would include a patient identifying number).

It is important that all of the listed identifiers be removed, and that no parts or derivatives of any of the aforementioned identifiers are left in the information submitted with a candidate's certification application.
For questions about this or any other certification topic, please contact BCCI at or 847.240.1014.

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