Frequently Asked Questions About the Disposal of Protected Health Information

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Office for Civil Rights

Frequently Asked Questions About the Disposal

of Protected Health Information

1.

What do the HIPAA Privacy and Security Rules require of covered entities when they dispose of

protected health information?

The HIPAA Privacy Rule requires that covered entities apply appropriate administrative, technical, and

physical safeguards to protect the privacy of protected health information (PHI), in any form. See 45

CFR 164.530(c). This means that covered entities must implement reasonable safeguards to limit

incidental, and avoid prohibited, uses and disclosures of PHI, including in connection with the disposal

of such information. In addition, the HIPAA Security Rule requires that covered entities implement

policies and procedures to address the final disposition of electronic PHI and/or the hardware or

electronic media on which it is stored, as well as to implement procedures for removal of electronic PHI

from electronic media before the media are made available for re-use. See 45 CFR 164.310(d)(2)(i) and

(ii). Failing to implement reasonable safeguards to protect PHI in connection with disposal could result

in impermissible disclosures of PHI.

Further, covered entities must ensure that their workforce members receive training on and follow the

disposal policies and procedures of the covered entity, as necessary and appropriate for each workforce

member. See 45 CFR 164.306(a)(4), 164.308(a)(5), and 164.530(b) and (i). Therefore, any workforce

member involved in disposing of PHI, or who supervises others who dispose of PHI, must receive

training on disposal. This includes any volunteers. See 45 CFR 160.103 (definition of “workforce”).

Thus, covered entities are not permitted to simply abandon PHI or dispose of it in dumpsters or other

containers that are accessible by the public or other unauthorized persons. However, the Privacy and

Security Rules do not require a particular disposal method

rs who dispose of PHI, must receive

training on disposal. This includes any volunteers. See 45 CFR 160.103 (definition of “workforce”).

Thus, covered entities are not permitted to simply abandon PHI or dispose of it in dumpsters or other

containers that are accessible by the public or other unauthorized persons. However, the Privacy and

Security Rules do not require a particular disposal method. Covered entities must review their own

circumstances to determine what steps are reasonable to safeguard PHI through disposal, and develop

and implement policies and procedures to carry out those steps. In determining what is reasonable,

covered entities should assess potential risks to patient privacy, as well as consider such issues as the

form, type, and amount of PHI to be disposed. For instance, the disposal of certain types of PHI such as

name, social security number, driver’s license number, debit or credit card number, diagnosis, treatment

information, or other sensitive information may warrant more care due to the risk that inappropriate

access to this information may result in identity theft, employment or other discrimination, or harm to an

individual’s reputation.

In general, examples of proper disposal methods may include, but are not limited to:

•

For PHI in paper records, shredding, burning, pulping, or pulverizing the records so that PHI is

rendered essentially unreadable, indecipherable, and otherwise cannot be reconstructed.

•

Maintaining labeled prescription bottles and other PHI in opaque bags in a secure area and using

a disposal vendor as a business associate to pick up and shred or otherwise destroy the PHI.

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Frequently Asked Questions About the

Disposal of Protected Health Information

the records so that PHI is

rendered essentially unreadable, indecipherable, and otherwise cannot be reconstructed.

•

Maintaining labeled prescription bottles and other PHI in opaque bags in a secure area and using

a disposal vendor as a business associate to pick up and shred or otherwise destroy the PHI.

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Frequently Asked Questions About the

Disposal of Protected Health Information

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Frequently Asked Questions About the

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•

For PHI on electronic media, clearing (using software or hardware products to overwrite media

with non-sensitive data), purging (degaussing or exposing the media to a strong magnetic field in

order to disrupt the recorded magnetic domains), or destroying the media (disintegration,

pulverization, melting, incinerating, or shredding).

For more information on proper disposal of electronic PHI, see the HHS HIPAA Security Series

3: Security Standards – Physical Safeguards. In addition, for practical information on how to

handle sanitization of PHI throughout the information life cycle, readers may consult NIST SP

800-88, Guidelines for Media Sanitization.

Other methods of disposal also may be appropriate, depending on the circumstances. Covered entities

are encouraged to consider the steps that other prudent health care and health information professionals

are taking to protect patient privacy in connection with record disposal. In addition, if a covered entity

is winding up a business, the covered entity may wish to consider giving patients the opportunity to pick

up their records prior to any disposition by the covered entity (and note that many states may impose

requirements on covered entities to retain and make available for a limited time, as appropriate, medical

records after dissolution of a business).

2

al. In addition, if a covered entity

is winding up a business, the covered entity may wish to consider giving patients the opportunity to pick

up their records prior to any disposition by the covered entity (and note that many states may impose

requirements on covered entities to retain and make available for a limited time, as appropriate, medical

records after dissolution of a business).

2.

May a covered entity dispose of protected health information in dumpsters accessible by the

public?

No, unless the protected health information (PHI) has been rendered essentially unreadable,

indecipherable, and otherwise cannot be reconstructed prior to it being placed in a dumpster. In general,

a covered entity may not dispose of PHI in paper records, labeled prescription bottles, hospital

identification bracelets, PHI on electronic media, or other forms of PHI in dumpsters, recycling bins,

garbage cans, or other trash receptacles generally accessible by the public or other unauthorized persons.

The HIPAA Privacy Rule requires that covered entities apply appropriate administrative, technical, and

physical safeguards to protect the privacy of PHI, in any form, including in connection with the disposal

of such information. See 45 CFR 164.530(c). In addition, the HIPAA Security Rule requires that

covered entities implement policies and procedures to address the final disposition of electronic PHI

and/or the hardware or electronic media on which it is stored. See 45 CFR 164.310(d)(2)(i). Depositing

PHI in a trash receptacle generally accessible by the public or other unauthorized persons is not an

appropriate privacy or security safeguard. Instead, covered entities must implement reasonable

safeguards to limit incidental, and avoid prohibited, uses and disclosures of PHI. Failing to implement

reasonable safeguards to protect PHI in connection with disposal could result in impermissible

disclosures of PHI

receptacle generally accessible by the public or other unauthorized persons is not an

appropriate privacy or security safeguard. Instead, covered entities must implement reasonable

safeguards to limit incidental, and avoid prohibited, uses and disclosures of PHI. Failing to implement

reasonable safeguards to protect PHI in connection with disposal could result in impermissible

disclosures of PHI.

For example, depending on the circumstances, proper disposal methods may include (but are not limited

to):

•

Shredding or otherwise destroying PHI in paper records so that the PHI is rendered essentially

unreadable, indecipherable, and otherwise cannot be reconstructed prior to it being placed in a

dumpster or other trash receptacle.

•

Maintaining PHI for disposal in a secure area and using a disposal vendor as a business associate

to pick up and shred or otherwise destroy the PHI.

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Frequently Asked Questions About the

Disposal of Protected Health Information

•

In justifiable cases, based on the size and the type of the covered entity, and the nature of the

PHI, depositing PHI in locked dumpsters that are accessible only by authorized persons, such as

appropriate refuse workers.

•

For PHI on electronic media, clearing (using software or hardware products to overwrite media

with non-sensitive data), purging (degaussing or exposing the media to a strong magnetic field in

order to disrupt the recorded magnetic domains), or destroying the media (disintegration,

pulverization, melting, incinerating, or shredding).

For more information on proper disposal of electronic PHI, see the HHS HIPAA Security Series

3: Security Standards – Physical Safeguards. In addition, for practical information on how to

handle sanitization of PHI throughout the information life cycle, readers may consult NIST SP

800-88, Guidelines for Media Sanitization.

3

dia (disintegration,

pulverization, melting, incinerating, or shredding).

For more information on proper disposal of electronic PHI, see the HHS HIPAA Security Series

3: Security Standards – Physical Safeguards. In addition, for practical information on how to

handle sanitization of PHI throughout the information life cycle, readers may consult NIST SP

800-88, Guidelines for Media Sanitization.

3.

May a covered entity hire a business associate to dispose of protected health information?

Yes, a covered entity may, but is not required to, hire a business associate to appropriately dispose of

protected health information (PHI) on its behalf. In doing so, the covered entity must enter into a

contract or other agreement with the business associate that requires the business associate, among other

things, to appropriately safeguard the PHI through disposal. See 45 CFR 164.308(b), 164.314(a),

164.502(e), and 164.504(e). Thus, for example, a covered entity may hire an outside vendor to pick up

PHI in paper records or on electronic media from its premises, shred, burn, pulp, or pulverize the PHI, or

purge or destroy the electronic media, and deposit the deconstructed material in a landfill or other

appropriate area.

4.

May a covered entity reuse or dispose of computers or other electronic media that store electronic

protected health information?

Yes, but only if certain steps have been taken to remove the electronic protected health information

(ePHI) stored on the computers or other media before its disposal or reuse, or if the media itself is

destroyed before its disposal. The HIPAA Security Rule requires that covered entities implement

policies and procedures to address the final disposition of ePHI and/or the hardware or electronic media

on which it is stored, as well as to implement procedures for removal of ePHI from electronic media

before the media are made available for reuse. See 45 CFR 164.310(d)(2)(i) and (ii)

dia itself is

destroyed before its disposal. The HIPAA Security Rule requires that covered entities implement

policies and procedures to address the final disposition of ePHI and/or the hardware or electronic media

on which it is stored, as well as to implement procedures for removal of ePHI from electronic media

before the media are made available for reuse. See 45 CFR 164.310(d)(2)(i) and (ii). Depending on the

circumstances, appropriate methods for removing ePHI from electronic media prior to reuse or disposal

may be by clearing (using software or hardware products to overwrite media with non-sensitive data) or

purging (degaussing or exposing the media to a strong magnetic field in order to disrupt the recorded

magnetic domains) the information from the electronic media. If circumstances warrant the destruction

of the electronic media prior to disposal, destruction methods may include disintegrating, pulverizing,

melting, incinerating, or shredding the media. Covered entities may contract with business associates to

perform these services for them.

For more information on proper disposal of ePHI and reuse of electronic media, see the HHS HIPAA

Security Series 3: Security Standards – Physical Safeguards. In addition, for practical information on

how to handle sanitization of PHI throughout the information life cycle, readers may consult NIST SP

800-88, Guidelines for Media Sanitization.

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Frequently Asked Questions About the

Disposal of Protected Health Information

5.

How should home health workers or other workforce members of a covered entity dispose of

protected health information that they use off of the covered entity’s premises?

The HIPAA Privacy Rule requires that covered entities develop and apply policies and procedures for

appropriate administrative, technical, and physical safeguards to protect the privacy of protected health

information (PHI), including through final disposition. See 45 CFR 164.530(c)

s of a covered entity dispose of

protected health information that they use off of the covered entity’s premises?

The HIPAA Privacy Rule requires that covered entities develop and apply policies and procedures for

appropriate administrative, technical, and physical safeguards to protect the privacy of protected health

information (PHI), including through final disposition. See 45 CFR 164.530(c). In addition, the HIPAA

Security Rule requires that covered entities implement policies and procedures to address the final

disposition of electronic PHI and/or the hardware or electronic media on which it is stored. See 45 CFR

164.310(d)(2)(i). The Rules are flexible and thus, do not specify particular types of disposal methods;

however, covered entities must ensure that the disposal method reasonably protects against

impermissible uses and disclosures of PHI and protects against reasonably anticipated threats or hazards

to the security of electronic PHI. See 45 CFR 164.530(c)(2) and 164.306(a). Whatever the disposal

method, a covered entity must ensure that appropriate workforce members, either working on the

premises or off-site, receive training on and follow the disposal policies and procedures of the covered

entity. See 45 CFR 164.530(b) and (i), as well as 164.306(a)(4) and 164.308(a)(5) with regard to

electronic PHI. These policies and procedures could require, for example, that employees or other

workforce members who use PHI off-site, including electronic PHI, return all PHI to the covered entity

for appropriate disposal. Or, for example, if appropriate under the circumstances, a covered entity could

give off-site workforce members the option of either properly shredding PHI in paper records

themselves or returning the PHI to the covered entity for disposal. In cases where workforce members

fail to comply with the covered entity’s disposal policies and procedures, the covered entity must apply

appropriate sanctions. See 45 CFR 164.530(e).

6

nder the circumstances, a covered entity could

give off-site workforce members the option of either properly shredding PHI in paper records

themselves or returning the PHI to the covered entity for disposal. In cases where workforce members

fail to comply with the covered entity’s disposal policies and procedures, the covered entity must apply

appropriate sanctions. See 45 CFR 164.530(e).

6.

Does the HIPAA Privacy Rule require covered entities to keep patients’ medical records for any

period of time?

No, the HIPAA Privacy Rule does not include medical record retention requirements. Rather, State laws

generally govern how long medical records are to be retained. However, the HIPAA Privacy Rule does

require that covered entities apply appropriate administrative, technical, and physical safeguards to

protect the privacy of medical records and other protected health information (PHI) for whatever period

such information is maintained by a covered entity, including through disposal. See 45 CFR 164.530(c).