Section 250.145 Health Care Sanctity and Privacy

TITLE 77: PUBLIC HEALTH

CHAPTER I: DEPARTMENT OF PUBLIC HEALTH

SUBCHAPTER c: HOSPITALS AND OUTPATIENT SERVICES CARE FACILITIES

PART 250 HOSPITAL LICENSING REQUIREMENTS

SECTION 250.145 HEALTH CARE SANCTITY AND PRIVACY

Section 250.145  Health Care Sanctity and Privacy

a)         For the purposes of this

Section, the following definitions shall apply:

1)

Administrative

volunteer – an individual who serves as a volunteer at a hospital in only an

administrative capacity.

2)

Law

enforcement agent – an agent of federal, State, or local law enforcement

authorized with the power to arrest or detain individuals, or manage the

custody of detained individuals, for civil immigration enforcement.

3)

Patient

– any person who has received or is receiving medical care, treatment, or

services from an individual or institution licensed to provide medical care or

treatment in this State.

(Section 6.14h(b) of the Act)

b)

Each

general acute care hospital shall adopt and implement a policy regarding

interactions with law enforcement agents by January 1, 2026. All other

hospitals shall adopt and implement a policy regarding interactions with law

enforcement agents by March 1, 2026. Each policy adopted under

the Act and

this Section shall

include, at a minimum:

1)

The

designation of a contact person or persons to be notified of all law

enforcement presence or information requests at the hospital and procedures to

respond to those requests

1, 2026. All other

hospitals shall adopt and implement a policy regarding interactions with law

enforcement agents by March 1, 2026. Each policy adopted under

the Act and

this Section shall

include, at a minimum:

1)

The

designation of a contact person or persons to be notified of all law

enforcement presence or information requests at the hospital and procedures to

respond to those requests. The designated contact person or persons shall be

legal counsel of the hospital or other individuals within the administration of

the hospital;

2)

Procedures

to verify the identity and authority of any law enforcement agent involved in

civil immigration activities at the hospital site, including, but not limited

to, the use of best efforts to request and document the first and last name of

the law enforcement agent, the name of the law enforcement agency, and the

badge number of any law enforcement agent presenting with a patient or

requesting information about a patient;

3)

Procedures

for designating space for law enforcement agents to remain and wait at a

hospital, considering public interest, staff safety, and patient needs;

provided, however, that a law enforcement agent may access the areas of the

hospital that the hospital's designated contact person approves if the law

enforcement agent:

A)

Complies

with hospital policy and State and federal law, including, but not limited to,

that the law enforcement agent has a valid judicial warrant or court order

signed by a judge or magistrate to accompany a patient in the law enforcement

agent's custody or otherwise be present in the facility, or

B)

Is

requested by hospital staff to respond to a safety or security issue within the

hospital;

4)

Procedures

to ensure that patients are provided with:

A)

A

notice of privacy policies in accordance with 45 CFR 164.520, including

information about the patient's right to request an amendment to the patient's

medical record, which shall be made available in the languages of the

populations of persons living w

by hospital staff to respond to a safety or security issue within the

hospital;

4)

Procedures

to ensure that patients are provided with:

A)

A

notice of privacy policies in accordance with 45 CFR 164.520, including

information about the patient's right to request an amendment to the patient's

medical record, which shall be made available in the languages of the

populations of persons living within the geographic area served by the hospital

in compliance with the Language Assistance Services Act and which may include a

request that any of the following information be deleted, redacted, or amended:

i)

Place

of birth;

ii)

Immigration or

citizenship status; or

iii)

Information

from birth certificates, passports, permanent resident cards, alien

registration cards, or employment authorization documents; and

B)

An

opportunity, at the earliest reasonable moment, to sign an authorization form

in order to permit the disclosure of information by the hospital to parents,

guardians, relatives, or other designees of the patient about the patient's

health status or hospital admission and discharge, which shall also be made

available in languages of the populations of persons living within the

geographic area served by the hospital in compliance with the Language

Assistance Services Act;

5)

Procedures

to ensure that any protected health information requested by a law enforcement

agent is released only in strict accordance with all applicable local, State,

and federal law, including, but not limited to, the Health Insurance

Portability and Accountability Act of 1996, as amended, and its implementing

regulations, including, but not limited to, the Privacy Rule (45 CFR 22, Parts

160, 162, and 164) and, including, but not limited to, 45 CFR 164.512(e) and

aw enforcement

agent is released only in strict accordance with all applicable local, State,

and federal law, including, but not limited to, the Health Insurance

Portability and Accountability Act of 1996, as amended, and its implementing

regulations, including, but not limited to, the Privacy Rule (45 CFR 22, Parts

160, 162, and 164) and, including, but not limited to, 45 CFR 164.512(e) and

(f);

6)

In

the case of a law enforcement agent seeking information for the purpose of

immigration enforcement, to the extent not in conflict with 45 CFR 164.512(e)

and (f), a procedure to release information only when the following

circumstances are met, and in strict compliance with:

A)

A

valid and accurate subpoena issued by a federal judge or magistrate

, as

determined by the designated contact person as referenced in subsection

250.145(b)(1), the administrative officer on duty, or other appropriately

trained staff;

B)

A

valid and accurate order issued by a federal judge or magistrate to require access

,

as determined by the designated contact person as referenced in subsection

250.145(b)(1), the administrative officer on duty, or other appropriately

trained staff; or

C)

A

valid and accurate warrant issued by a federal judge or magistrate

, as

determined by the designated contact person as referenced in subsection

250.145(b)(1), the administrative officer on duty, or other appropriately

trained staff;

7)

Procedures

to ensure annual and, as deemed reasonably necessary by the hospital, episodic

training on

the

policy

regarding interactions with law enforcement

agents

to

:

A)

All

hospital clinical health care staff, including, but not limited to, intake staff,

emergency room staff, and independent contractors who provide clinical

services;

B)

Security

personnel;

C)

Designated

contact persons; and

D)

Administrative

volunteers;

8)

Procedures

to ensure all policies of the hospital comply with

Section 6.14h of the Act

and this Section; and

9)

A

requirement that a hospital or its agents shall not

e staff, including, but not limited to, intake staff,

emergency room staff, and independent contractors who provide clinical

services;

B)

Security

personnel;

C)

Designated

contact persons; and

D)

Administrative

volunteers;

8)

Procedures

to ensure all policies of the hospital comply with

Section 6.14h of the Act

and this Section; and

9)

A

requirement that a hospital or its agents shall not retaliate against a

patient, employee, or agent who files a complaint under

Section 6.14h of

the Act and this Section.  (Section 6.14h(c) of the Act)

c)

The

policies required by

and compliant with subsection (b)

shall be

submitted to the Department. General acute care hospitals shall submit the

policies to the Department no later than January 1, 2026. All other hospitals

shall submit the policies to the Department no later than March 1, 2026

.

(Section 6.14h(d) of the Act)

d)

Hospitals

shall post, either by physical or electronic means, in a conspicuous place

within the hospital, which is accessible to patients, employees, and visitors,

a description, provided by the Department, regarding the phone number that

individuals can call to learn about their immigration rights. Notices under

this Section shall be posted in the predominant language or languages spoken in

the hospital's service area.

(Section 6.14h(e) of the Act)

e)

By

January 15, 2026, the Department will notify any general acute care hospital

that has failed to provide a copy of the policy required under

and

compliant with Section 6.14h of the Act and this Section,

and by March 15,

2026, the Department

will

notify all other hospitals that have failed to

provide a copy of the policy required under

and compliant with Section

6.14h of the Act and this Section.

1)

A

hospital receiving

this

notice shall have

seven

working days to

provide a copy of the policy.

2)

The

failure of a hospital to submit a copy of a policy within

seven

working

days

will

subject the hospital to the imposition of a fine by the

Department

er hospitals that have failed to

provide a copy of the policy required under

and compliant with Section

6.14h of the Act and this Section.

1)

A

hospital receiving

this

notice shall have

seven

working days to

provide a copy of the policy.

2)

The

failure of a hospital to submit a copy of a policy within

seven

working

days

will

subject the hospital to the imposition of a fine by the

Department. The Department

will

impose a fine of up to $500 per day

until the hospital files the policy.

(Section 6.14h(f) of the Act)

Notices of fines will be issued in accordance with Part 100 Practice and

Procedure in Administrative Hearings (77 Ill. Admin. Code 100).

f)

The

Department

will

investigate and respond to complaints from patients,

employees, and the public alleging noncompliance with

subsection (b). The

Department will not determine the validity or accuracy of a subpoena, order, or

warrant, as referenced in (b)(6)(A-C).

A hospital and its agents shall not

retaliate against a patient, employee, or agent who files a complaint under

Section 6.14h of the Act and this Section.  (Section 6.14h(g) of the Act)

g)

All

hospital personnel, including administrative volunteers, shall be forever held

harmless from any civil, criminal, or other liability that may arise, now or in

the future, as a result of their reasonable compliance with the provisions of

Section 6.14h of the Act and this Section.  (Section 6.14h(h) of the Act)

h)

Nothing

in

Section 6.14h of the Act or this Section

affects a hospital's

obligation as a mandated reporter or to otherwise respond to instances of

suspected crime on the premises.

(Section 6.14h(i) of the Act)

i)          Section

6.14h of the Act and this Section are

not intended to conflict with federal

law or stand as an obstacle to the enforcement of federal laws

.  (Section

6.14h(j) of the Act)