Civil Rights and Privacy Rule Compliance Activities

As the Department's civil rights, conscience and religious freedom, and health privacy rights law enforcement agency, OCR investigates complaints, enforces rights, and promulgates regulations, develops policy and provides technical assistance and public education to ensure understanding of and compliance
with non-discrimination and health information privacy laws.

Agency - Department of Health and Human Services

The Department of Health and Human Services is the Federal government's principal agency for protecting the health of all Americans and providing essential human services, especially to those who are least able to help themselves.

Office - See Regional Agency Offices.

New England Region Boston, MA (services Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont) Susan Pezzullo-Rhodes, Regional Manager Office for Civil Rights U. S. Department of Health and Human Services Government Center J.F.

Kennedy Federal Building - Room 1875 Boston, MA 02203 Voice phone 800-368-1019 FAX (617) 565-3809 TDD (617) 565-1343 Eastern & Caribbean Region New York, NY (services New Jersey, New York, Puerto Rico, Virgin Islands) Linda C.

Colon, Regional Manager Office for Civil Rights U. S. Department of Health and Human Services Jacob Javits Federal Building 26 Federal Plaza - Suite 3312 New York, NY 10278 Voice Phone 800-368-1019 FAX (212) 264-3039 TDD (212) 264-2355 Mid-Atlantic Region Philadelphia, PA (services Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, West Virginia) Barbara Holland, Regional Manager Office for Civil Rights U. S. Department of Health and Human Services 150 S.

Independence Mall West Suite 372, Public Ledger Building Philadelphia, PA 19106-9111 Main Line 800-368-1019 FAX (215) 861-4431 TDD (215) 861-4440 Southeast Region Atlanta, GA (services Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee) Timothy Noonan, Regional Manager Office for Civil Rights U. S. Department of Health and Human Services Atlanta Federal Center, Suite 3B70 61 Forsyth Street, S.W. Atlanta, GA 30303-8909 Voice Phone 800-368-1019 FAX (404) 562-7881 TDD (404) 331-2867 Midwest Region Chicago, IL (services Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin, Iowa, Kansas, Missouri, Nebraska) Steven Mitchell, Acting Regional Manager Office for Civil Rights U. S. Department of Health and Human Services 233 N.

Michigan Ave., Suite 240 Chicago, IL 60601 Voice Phone 800-368-1019 FAX (312) 886-1807 TDD (312) 353-5693 Southwest Region Dallas, TX (services Arkansas, Louisiana, New Mexico, Oklahoma, Texas) Marisa Smith, Regional Manager Office for Civil Rights U. S. Department of Health and Human Services 1301 Young Street, Suite 1169 Dallas, TX 75202 Voice Phone 800-368-1019 FAX (214) 767-0432 TDD (214) 767-8940 Rocky Mountain Region Denver, CO (services Colorado, Montana, North Dakota, South Dakota, Utah, Wyoming) Andrea Oliver, Regional Manager Office for Civil Rights U. S. Department of Health and Human Services 1961 Stout Street, Rm.

08-148 Denver, CO 80294 Voice Phone 800-368-1019 FAX (303) 844-2025 TDD (303) 844-3439 Pacific Region San Francisco, CA (services American Samoa, Arizona, California, Guam, Hawaii, Nevada, Alaska, Idaho, Oregon, Washington) Michael Leoz, Regional Manager Office for Civil Rights U. S. Department of Health and Human Services 90 7th Street, Suite 4-100 San Francisco, CA 94103 Voice Phone 800-368-1019 FAX (415) 437-8329 TDD (415) 437-8311.
Website Address

http://www.hhs.gov/ocr




Program Accomplishments

Fiscal Year 2016: OCR resolved over 28,000 complaints alleging discrimination or a health information privacy or security violation. Fiscal Year 2017: OCR projects to resolve approximately 29,000 total complaints alleging discrimination or a health information privacy or security violation. Fiscal Year 2018: OCR projects to resolve approximately 31,000 total complaints alleging discrimination or a health information privacy or security violation.

Uses and Use Restrictions

The Office for Civil Rights (OCR) in the Department of Health and Human Services (HHS) is responsible for promoting and ensuring that people have equal access to and the opportunity to participate in and receive services from all HHS-funded programs without facing unlawful discrimination, that the privacy of their health information is protected, and that electronic protected health information is safeguarded against unauthorized use or disclosure.

These HHS funded programs are provided through state agencies, nursing homes, skilled nursing facilities, medical laboratories, hospitals, day care centers, social service agencies and other providers.

Any person who believes that an individual has been discriminated against in the provision of these services because of race, color, national origin, disability, age, sex or religion, may file a complaint with OCR.

An individual who believes that discrimination on the basis of disability has occurred in a health or social services program of a state or local government entity may file a complaint with OCR under Title II of the Americans with Disabilities Act of 1990, regardless of whether the entity receives Federal funds.

Individuals may also file complaints of denials of health care for reasons other than the need and availability of services, by recipients of Hill-Burton grants and loans.

In addition, a person may file a complaint under the Multiethnic Placement Act of 1994, as amended by Section 1808 of the Small Business Job Protection Act of 1996, alleging that an adoption or foster care agency or entity funded by HHS discriminatorily relied on a parent?s or child's race, color, or national origin in making a placement decision.

OCR will investigate complaints and take steps to ensure compliance with applicable civil rights laws. OCR also enforces the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule and Security Rule as well as the HITECH Breach Notification Rule and the confidentiality provisions of the Patient Safety and Quality Improvement Act (PSQIA) of 2005.

OCR's activities under the Privacy, Security and Breach Notification Rules include enforcement actions, including conducting investigations, taking compliance actions, and making penalty determinations, and conducting public education, technical assistance and other outreach activities: to health care providers, health care clearinghouses, health plans, and business associates of covered entities to ensure that they understand their responsibilities under the Rules; to other entities that may be impacted by the Rules, including Federal, State and local government agencies, and researchers; and to consumers, to inform them of their rights under the Privacy Rule.

Anyone who believes that a person, agency or organization covered under the HIPAA Privacy and Security Rules ('a covered entity') has violated the Privacy and/or Security Rules may file a complaint with OCR.

In addition, the Breach Notification Rule requires HIPAA covered entities to promptly notify affected individuals of a breach, as well as the HHS Secretary and the media in cases where a breach affects more than 500 individuals; OCR is required to publish a list of entities that incur large breaches.

Where a breach of unsecured protected health information occurs at or by a business associate, the business associate must notify the covered entity following the discovery of the breach.

Additionally, the HITECH Act now makes business associates accountable for protecting the privacy and security of protected health information and directly liable for criminal and civil penalties for violations of HIPAA and Security Rules. OCR's activities under PSQIA include administering an enforcement program regarding the confidentiality protections, including conducting investigations, taking compliance actions, making penalty determinations, and interpreting standards for confidentiality protections and the enforcement program for guidance and technical assistance to Patient Safety Organizations (PSOs), providers and public information.

Eligibility Requirements

Applicant Eligibility

Anyone who believes he or she has been discriminated against in the manner outlined, seeks information concerning civil rights, and recipients of Federal financial assistance who desire technical assistance and information for the purpose of assuring their compliance with nondiscrimination laws.

Regarding the HIPAA Privacy and Security Rules, anyone who believes that the Privacy and/or Security Rules have been violated in the manner outlined or who seeks information about these Rules; consumers that need to know their rights under the Privacy Rule; and entities that need technical assistance and information for the purpose of assuring compliance with the Privacy and Security Rules.

Beneficiary Eligibility

Individuals subject to discrimination and recipients who require technical assistance and information. Regarding the HIPAA Privacy Rule, individuals subject to violation of their health information privacy, covered entities, and others needing or seeking technical assistance and information concerning the Rule.

Credentials/Documentation

No Credentials or documentation are required. This program is excluded from coverage under 2 CFR 200, Subpart E - Cost Principles.

Aplication and Award Process

Preapplication Coordination

Preapplication coordination is not applicable.

Environmental impact information is not required for this program.

This program is excluded from coverage under E.O.

12372.

Application Procedures

This program is excluded from coverage under 2 CFR 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards. Complaints of discrimination and alleged violations of the HIPAA Privacy and Security Rules may be filed, and technical assistance information and public education may be requested, at the Headquarters and Regional Office locations of the Office for Civil Rights.

Award Procedures

None.

Deadlines

Not Applicable.

Authorization

Title VI of the Civil Rights Act of 1964, as amended; Sections 504 and 508 of the Rehabilitation Act of 1973, , as amended; Title IX of the Education Amendments of 1972, as amended; Age Discrimination Act of 1975, as amended; Hill-Burton Community Service Assurance, Titles VI and XVI of the Public Health Service Act, , as amended; Drug Abuse Offense and Treatment Act of 1972, Section 407; Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970, Section 321, as amended; Nondiscrimination Provisions of the Low-Income Home Energy Assistance Act of 1981, 42 U.S.C. 8625; Nondiscrimination Provisions of the Community Services Block Grant Program, 42 U.S.C. 9918; Family Violence Prevention and Services Act, as amended, Section 306(c)(2), Public Law 111-320; Americans with Disabilities Act of 1990, Title II, Subtitle A, Public Law 101-336; Small Business Job Protection Act of 1996, Section 1808, Public Law 104-188; Section 1557 of the Patient Protection and Affordable Care Act; Section 1553 of the Affordable Care Act; Federal Conscience Rights Statutes, which include the Church Amendments, (42 U.S.C. 300a-7), the Coats-Snowe Amendment (42 U.S.C. 238n), and the Weldon Amendment (Public Law 115-31, section 507(d)); Maternal and Child Health Services Block Grant Nondiscrimination Provision (42 U.S.C. 708);, Preventive Health and Health Services Nondiscrimination Provision (42 U.S.C. 300w-7); Substance Abuse Prevention and Treatment Block Grant and Community Mental Health Services Block Grant Nondiscrimination Provision (42 U.S.C. 300x-57); Projects in Assistance to Transition from Homelessness Project Grants Nondiscrimination Provision (42 U.S.C. 290c-33); Equal Employment Opportunity Provision in the Public Telecommunications Financing Act of 1978, section 309, (47 U.S.C. 398(b)) as amended; Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C. 1320d-8, 45 CFR Part 160 and Subparts A, C and E of Part 164--Standards for Privacy of Individually Identifiable Health Information (the 'Privacy Rule') and Standards for the Protection of Electronic Protected Health Information (the 'Security Rule'); Public Health Service Act, Title IX, 42 U.S.C. 299b-22, as amended by the Patient Safety and Quality Improvement Act of 2005, Public Law 109-41; Part C of title XI of the Social Security Act, 42 U.S.C. 1320d-d-8, as amended by Section 105 of the Genetic Information Nondiscrimination Act of 2008 (GINA), Public Law 110?233; Subtitle D of the Health Information Technology for Economic and Clinical Health (HITECH) Act, Public Law 111-5, 123 Stat. 115 (2009), and 45 CFR Subpart D of Part 164 - Breach Notification for Unsecured Protected Health Information (the 'Breach Notification Rule'); Title IV of the 21st Century Cures Act, Public Law 114-255, 130 Stat. 1033 (2016).

Range of Approval/Disapproval Time

A complaint must be filed not later than 180 days of the alleged discrimination, unless the time for filing is waived for good cause. Complaints under the Privacy and/or Security Rules must be filed within 180 days of the date when the complainant knew, or should have known, that the act or omission complained of occurred, unless the time limit is waived for good cause. Complaint processing time varies considerably based on the type of complaint, the complexity of the issues, and current OCR caseload.

Appeals

Individuals can appeal a civil rights discrimination complaint determination in some instances by submitting, in writing, a request for reconsideration to the Director, Office for Civil Rights. OCR imposes civil money penalties (CMPs) on covered entities and their business associates found to be in violation of the HIPAA Privacy, Security and/or Breach Notification Rules. If CMPs are imposed, the covered entity, or any applicable business associates, may request a hearing in which an HHS administrative law judge (ALJ) decides if the CMPs are supported by the evidence in the case. OCR is required to present the evidence to support the imposition of CMPs to the ALJ. The covered entity and/or business associate(s) may also then appeal the ALJ's decision to the HHS Departmental Appeals Board (DAB) and ultimately to the U.S. Courts of Appeal.

Renewals

Not Applicable.

Assistance Considerations

Formula and Matching Requirements

This program has no statutory formula. This program has no matching requirements. This program does not have MOE requirements.

Length and Time Phasing of Assistance

Not applicable. See the following for information on how assistance is awarded/released: Not applicable.

Post Assistance Requirements

Reports

No reports are required.

Audits

No audits are required for this program.

Records

None.

Financial Information

Account Identification

75-0135-0-1-751 - Office for Civil Rights.

Obigations

(Investigation of Complaints) FY 16 $38,798,000; FY 17 est $38,798,000; and FY 18 est $32,530,000

Range and Average of Financial Assistance

Not applicable.

Regulations, Guidelines, and Literature

Title VI of the Civil Rights Act of 1964--the implementing regulation (45 CFR 80), 'Your Rights Under Title VI of the Civil Rights Act of 1964 fact sheet, 'Know Your Rights' brochure regarding national origin discrimination and limited English proficiency, a video in VHS and DVD formats entitled 'Title VI Limited English Proficiency'; Section 504 of the Rehabilitation Act of 1973--the implementing regulation for HHS funded programs and activities (45 CFR 84), and fact sheets 'Your Rights Under Section 504,' 'Your Rights as a Person with HIV Infection, AIDS, or Related Conditions,' 'Your Rights Under Section 504 and the Americans with Disabilities Act,' and the HHS Section 504 federally conducted regulation (45 CFR 85); Age Discrimination Act of 1975--implementing regulations, HHS (45 CFR 91) and government-wide (45 CFR 90), and fact sheet 'Your Rights Under the Age Discrimination Act'; Federal Health Care Provider Conscience Protection Statutes (including the Church Amendments, Section 245 of the Public Health Service Act, and the Weldon Amendment) implementing regulation (45 CFR 88), and, 'Your Rights Under the Federal Health Care Provider Conscience Protection Laws' fact sheet, Community Service Assurance of the Hill-Burton regulation (42 CFR 124) and fact sheet 'Community Service Assurance Under the Hill-Burton Act'; Sex Discrimination in Health-Related Training Programs regulation (45 CFR 83); fact sheets on: Section 1808/Multiethnic Placement Act (MEPA); the Americans with Disabilities Act (ADA); 'How to File a Discrimination Complaint with OCR'; 'Know Your Civil Rights'; Civil Rights Frequently Asked Questions; a video presentation: OCR guidance on Temporary Assistance for Needy Families (TANF) and Disability; OCR guidance documents and questions and answers on MEPA; various technical assistance materials for Medicare providers and applicants, including a sample nondiscrimination policy, LEP policy, auxiliary aids policy, accessibility policy, and grievance procedure, and various other civil rights publications. HIPAA regulations and standards: The Privacy Rule and the Security Rule, 45 CFR Part 160 and Subparts A, C and E of Part 164; the Breach Notification Rule, 45 CFR Subpart D of Part 164; 'Your Health Information Privacy Rights'; 'Privacy, Security, and the Electronic Health Record'; 'Understanding the HIPAA Notice, and Sharing Health Information with Family and Friends.' These consumer-facing brochures are also available in eight languages: Korean, Vietnamese, Simplified Chinese, Traditional Chinese, Polish, Russian, Tagalog, and Spanish. OCR also has sight videos available on various aspects of the HIPAA Privacy Rule for consumers and two designed for health care providers, as well as posters and a brochure entitled 'Information is Powerful Medicine.' Materials designed for covered entities designed for covered entities and their business associates include 'Guidance on Risk Analysis Requirements Under the Security Rule' fact sheets and guidance on specific aspects of the Privacy and Security Rules; an entire webpage dedicated to educating covered entities on cybersecurity risks and how to address them via compliance with the HIPAA Security and Breach Notification Rules; and additional compliance tools such as 'Am I a Covered Entity', 'the Security Rule Educational Paper Series', and Frequently Asked Questions (FAQs). A complete list of HIPAA-related publications is available. There is also a brochure titled 'Safeguarding Civil Rights Health Information Privacy,' which provides general information about the Office for Civil Rights and its services. All literature is available at no charge; however, because of budgetary constraints and availability of stock, quantities may be limited. Most publications can be downloaded from OCR's website and are available in languages other than English. All publications are available in alternative formats for individuals with disabilities.

Information Contacts

Regional or Local Office

See Regional Agency Offices. New England Region Boston, MA (services Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont) Susan Pezzullo-Rhodes, Regional Manager Office for Civil Rights U.S. Department of Health and Human Services Government Center J.F. Kennedy Federal Building - Room 1875 Boston, MA 02203 Voice phone 800-368-1019 FAX (617) 565-3809 TDD (617) 565-1343 Eastern & Caribbean Region New York, NY (services New Jersey, New York, Puerto Rico, Virgin Islands) Linda C. Colon, Regional Manager Office for Civil Rights U.S. Department of Health and Human Services Jacob Javits Federal Building 26 Federal Plaza - Suite 3312 New York, NY 10278 Voice Phone 800-368-1019 FAX (212) 264-3039 TDD (212) 264-2355 Mid-Atlantic Region Philadelphia, PA (services Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, West Virginia) Barbara Holland, Regional Manager Office for Civil Rights U.S. Department of Health and Human Services 150 S. Independence Mall West Suite 372, Public Ledger Building Philadelphia, PA 19106-9111 Main Line 800-368-1019 FAX (215) 861-4431 TDD (215) 861-4440 Southeast Region Atlanta, GA (services Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee) Timothy Noonan, Regional Manager Office for Civil Rights U.S. Department of Health and Human Services Atlanta Federal Center, Suite 3B70 61 Forsyth Street, S.W. Atlanta, GA 30303-8909 Voice Phone 800-368-1019 FAX (404) 562-7881 TDD (404) 331-2867 Midwest Region Chicago, IL (services Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin, Iowa, Kansas, Missouri, Nebraska) Steven Mitchell, Acting Regional Manager Office for Civil Rights U.S. Department of Health and Human Services 233 N. Michigan Ave., Suite 240 Chicago, IL 60601 Voice Phone 800-368-1019 FAX (312) 886-1807 TDD (312) 353-5693 Southwest Region Dallas, TX (services Arkansas, Louisiana, New Mexico, Oklahoma, Texas) Marisa Smith, Regional Manager Office for Civil Rights U.S. Department of Health and Human Services 1301 Young Street, Suite 1169 Dallas, TX 75202 Voice Phone 800-368-1019 FAX (214) 767-0432 TDD (214) 767-8940 Rocky Mountain Region Denver, CO (services Colorado, Montana, North Dakota, South Dakota, Utah, Wyoming) Andrea Oliver, Regional Manager Office for Civil Rights U.S. Department of Health and Human Services 1961 Stout Street, Rm. 08-148 Denver, CO 80294 Voice Phone 800-368-1019 FAX (303) 844-2025 TDD (303) 844-3439 Pacific Region San Francisco, CA (services American Samoa, Arizona, California, Guam, Hawaii, Nevada, Alaska, Idaho, Oregon, Washington) Michael Leoz, Regional Manager Office for Civil Rights U.S. Department of Health and Human Services 90 7th Street, Suite 4-100 San Francisco, CA 94103 Voice Phone 800-368-1019 FAX (415) 437-8329 TDD (415) 437-8311.

Headquarters Office

Director, Office for Civil Rights Hubert H. Humphrey Building Mail Stop Room 509-F6 200 Independence Avenue, SW , Washington, District of Columbia 20201 Email: OCRMail@hhs.gov Phone: 800-368-1019

Criteria for Selecting Proposals

Not Applicable.



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