Sections 1 & 2

• • Model Policies and Procedures Regarding Information Sharing

    [Healthcare facility] should develop and post its model policies, if at all possible in the languages commonly spoken in the local community, and make these policies accessible on the [healthcare facility’s] website. Staff, including any relevant volunteers, should be well-trained in these policies and procedures.

    [Healthcare facility] shall designate a healthcare facility administrator to handle immigration issues, ensuring staff members and relevant volunteers are adequately dealing with immigration enforcement inquiries and requests, dissemination of information to patients, and compliance with internal procedures.

    [Healthcare facility] should implement a policy that is protective of patient information, under which [healthcare facility] staff members and volunteers disclose patient information only when required or expressly authorized to do so by law.

    [Healthcare facility] and [designated healthcare facility administrator] should consult legal counsel to help [healthcare facility] determine when and to what extent [healthcare facility] is required to comply with administrative requests.

    [Healthcare facility] shall require that an immigration enforcement official provide his/her badge or identification card to be photocopied by [healthcare facility] personnel.

    For responding to requests issued by immigration enforcement officers, [healthcare facility] should develop a verification procedure to determine and document:
    – The specific agency the requester is from
    – Whether the requester has law enforcement power
    – The specific types of protected health information the requester seeks
    – The reason the requester wants the information, including any legal authority claimed.

    [Healthcare facility] should develop procedures for handling information requests by telephone, such as requiring a call-back process through publicly listed agency phone numbers. Staff members and volunteers receiving immigration inquiries and requests shall first consult with the [designated healthcare facility administrator] to ensure that correct protocols are followed.

    [Healthcare facility] should establish policies that provide guidance on determining whether a document labeled “subpoena,” “warrant,” or “summons” has been issued by a court or judicial officer, and whether the request for the PHI is narrowly tailored as required by HIPAA. Often such requests are handled by the [healthcare facility’s] privacy officer or medical records department, to assure that information is disclosed appropriately. If possible, [healthcare facility] should consult with competent legal counsel each time on such matters.

  • Model Policies and Procedures Regarding Information Sharing Continued

    If [healthcare facility] is required to make a disclosure of patient information to immigration enforcement authorities without the patient’s authorization in compliance with a court order or judicial warrant, then the [healthcare facility] should document the disclosure in compliance with facility policies and procedures. Such documentation should include information that supported the decision to disclose the information. Disclosures to law enforcement are subject to the accounting-of-disclosures requirement under the HIPAA Privacy Rule.

  • Model Policies for Information Notice to Patients or Representatives

    [Healthcare facility] should post and issue general information policies telling patients of their privacy rights and remedies.

    [Healthcare facility] should give assurances that [healthcare facility] will not release information to third parties for immigration enforcement purposes, except as required or expressly authorized by law or court order.

    [Healthcare facility] should provide a comprehensive list of privacy protections, under both federal law and California law (including a patient’s right of action for disclosures in violation of CMIA).

    Healthcare facility should post information guides regarding immigrant patient rights, including the right to remain silent. While immigration enforcement at [healthcare facility] is limited by the “protected area” guidance described previously, immigration agents may enter a public area of [healthcare facility] without a warrant or the facility’s consent and may question any person present (with that person’s consent).

Section 3

• • Model Policies for Monitoring and Receiving Visitors into Healthcare Facilities

    No visitor—which would include immigration enforcement officers—shall enter or remain on [healthcare facility] grounds without having registered with [healthcare facility]’s designee. If there are no exigent circumstances necessitating immediate action, and if the visitor does not possess a judicial warrant or court order that provides a basis for the visit, the visitor must provide the following information to [healthcare facility]’s designee:
    ✓ Name, address, occupation;
    ✓ Age, if less than 21 years;
    ✓ Purpose in entering [healthcare facility];
    ✓ Proof of identity.
    (Try to obtain this information even from a visitor or officer with a court order.)

    [Healthcare facility] shall post signs at the entrances of the facility to notify outsiders of the hours of operation and requirements for registration.

    [Healthcare facility] personnel shall report entry by immigration enforcement officers to the [designated healthcare facility administrator], as would be required for any unexpected or unscheduled outside visitor coming into the facility.

  • Model Policies for Responding to Immigration Law Enforcement at Healthcare Facilities

    As soon as possible, [healthcare facility] personnel shall notify the [designated healthcare facility administrator] of any request (including subpoenas, petitions, complaints, warrants, or court orders) by an immigration law enforcement officer to access a healthcare facility or a patient, or any request for the review of [healthcare facility] documents.
    In addition to notifying the [designated healthcare facility administrator], [healthcare facility] personnel shall take the following steps in response to an officer present at the healthcare facility for immigration enforcement purposes:

    1. Advise the officer that before proceeding with his or her request, [healthcare facility] staff must first notify and receive direction from the [designated healthcare facility administrator].

    2. Ask to see, and make a copy of or note, the officer’s credentials (name and badge number). Also ask for and copy or note the telephone number of the officer’s supervisor.

    3. Ask the officer to explain the purpose of the officer’s visit, and note the response.

    4. Ask the officer to produce any documentation that authorizes healthcare facility access.

    5. Make copies of all documents provided by the officer.

    6. Decline to answer questions posed by the officer and direct him or her to speak to the [designated healthcare facility administrator].

    7. State that [healthcare facility] does not consent to entry of [healthcare facility] or portions thereof.

    8. Without expressing consent, respond according to the requirements of the officer’s documentation. If the officer has:

    – An ICE administrative “warrant” (see Appendices A and B): Immediate compliance is not required. Inform the officer that [healthcare facility] cannot respond to the warrant until after it has been reviewed by a designated administrator. Provide a copy of the warrant to the designated administrator as soon as possible.

    – A federal judicial warrant (either a search-and-seizure warrant or an arrest warrant; see Appendices C and D): Prompt compliance usually is required, but, where feasible, staff should consult with legal counsel before responding.

    – A subpoena for production of documents or other evidence (see Appendices E and F): Immediate compliance is not required. Inform the officer that [healthcare facility] cannot respond to the subpoena until after it has been reviewed by a designated administrator. Give your copy of the subpoena to the designated administrator or legal counsel as soon as possible.

    – A notice to appear (see Appendix G): This document is not directed at the healthcare facility. Healthcare facility staff is under no obligation to deliver or facilitate service of this document to the person named in the document. If you get a copy of the document, give it to your designated healthcare facility administrator as soon as possible.

    9. Document the officer’s actions in as much detail as possible when he or she enters [healthcare facility] premises, but without interfering with the officer’s movements.

    10. If the officer orders staff to provide immediate access to facilities, [healthcare facility] staff should comply with the officer’s order and also immediately contact a designated administrator. Personnel also should not attempt to physically interfere with the officer, even if the officer appears to be acting without consent or appears to be exceeding the purported authority given by a warrant or other document. If an officer enters the premises without authority, [healthcare facility] personnel shall simply document the officer’s actions while at the facility.

    11. [Healthcare facility] staff should complete an incident report that includes the information gathered as described above and the officer’s statements and actions.

  • Model Policies for Parental Notification of Immigration Law Enforcement Actions

    [Healthcare facility] personnel must receive consent from a minor patient’s parent or guardian (provided the child is not legally regarded as his or her own personal representative of his or her medical records) before a minor patient can be interviewed or searched by any officer seeking to enforce the civil immigration laws at [healthcare facility], unless the officer presents a valid, effective warrant signed by a judge, or presents a valid, effective court order.

    [Healthcare facility] personnel shall immediately notify the minor patient’s parent or guardian if a law enforcement officer requests or gains access to a patient for immigration enforcement purposes, unless such access was in compliance with a judicial warrant or subpoena that restricts the disclosure of the information to the parent or guardian.