TDCJ Health Manual

TDCJ Health Manual

Effective Date: 10/95, Revised: 08/03, Replaces: 7-1B, Formulated: 06/92, Number: H-61.1



To provide guidelines that insure offender health information receives appropriate confidential safeguards.


I. In accordance with the Health Insurance Portability and Accountability Act (HIPAA), any individually identifiable health information in any form, either verbal, written or electronic, concerning the provision of health care to an offender is to be protected and safeguarded against inappropriate use or release. Any individually identifiable health information created or maintained on an offender will be known as Protected Health Information (PHI). Texas Department of Criminal Justice (TDCJ) appropriately protects and maintains offender PHI as required by federal and state law (Medical Practice Act, Art. 4495b, Section 5.08 and the Texas Health and Safety Code). Offender PHI will be protected and managed in the same manner PHI is managed for free world patients. PHI is considered confidential and may only be used and disclosed pursuant to this policy. Furthermore, verbal exchanges between Health Services staff concerning offender health information must take place in a confidential manner to ensure only those individuals privileged to obtain the information concerning offenders health care is not left unattended or in public view and is given only to individuals who are authorized to receive it.

II. Access to Health Records
The Assistant Director of Health Information Management (HIM) is the custodian for health records and must ensure only the appropriate individuals gain access to the offender PHI. Offender PHI may be disclosed only in the following circumstances:


* If the facility medical staff is asked to provide specific information or is asked to provide access to any electronic medical record system for a TDCJ official or employee regarding offender PHI, the TDCJ administration must provide reasonable assurances before staff can provide access to requested PHI.

1.The following is a list of personnel who can request PHI:
a.* TDCJ Health Services staff and designated agents
b.* Members of the Texas Board of Criminal Justice
c.* Members of the Attorney General’s staff and members of the TDCJ and TDCJ-ID General Counsel Staff
d.* Health care personnel of a correctional institution in which the offender is detained if the disclosure is for the sole purpose of providing health care to the offender
e.* TDCJ Office of the Inspector General staff members conducting formal investigations and Counsel Substitutes
f.* The Board of Pardons and Parole, and the Parole Division, their employees and designated agents
g.* The Governor, his/her employees and designated agents
h.* TDCJ employees specifically designated by the Division Director for Health Services.
i.* The facility administrator or his/her designee. Each facility health records department shall be provided and maintain a facility administrator’s designee list.
j.*Those state agencies authorized by Section 614.017 of the Texas Health and Safety Code to continue the care of Special Needs Offenders released from TDCJ to their custody.

2.In the request for the offender PHI or access to an electronic record, the personnel listed above must provide reasonable assurances the PHI will be used for, at least, one of the following reasons:
a. The provision of health care to offenders,
b. The health and safety of the offender or other offenders;
c. The health and safety of the officers or employees of or others at the correctional institutions.
d. The health and safety of such individuals and officers or other persons responsible for transporting of inmates or their transfer from one institution, facility, or setting to another;
e. Law enforcement on the premises of the correctional institution; and,
f. The administration and maintenance of safety, security and good order of the correctional institution.

If facility medical staff is asked to provide offender PHI or is asked to provide access to any electronic medical record system containing offender PHI regarding a specific offender or to a group of offenders’ PHI for any requestor who is not a TDCJ official or employee, the non TDCJ individual or entity must present a valid, executed authorization for the release of information from the offender or the offender’s personal representative. For example, the following individuals and entities will be required to obtain the offender’s authorization to release PHI prior to the release of PHI.

1. The offender or the offender’s personal representative;
2. Members of the offender’s family;
a. The unit health authority (TTUHSC)/ management team (UTMB) is responsible for responding to all telephone inquires regarding health related matters from family members of offenders. The offender’s written valid authorization must be obtained prior to releasing any health information to the family member.
3. Members of the Texas Legislature and their employees or designated agent. Responses to inquiries from legislators must be copied to the office of the Division Director for Health Services.
4. Healthcare professionals from the free world medical community, if the offender is not being treated for emergency treatment. For example, an offender’s authorization is required if an offender wishes to have his or her medical condition reviewed by an outside freeworld health care professional or if the offender has been released back into the freeworld population and the offender’s new healthcare professional wishes to obtain records of the offender’s treatment for review as a new patient visit.

Under certain circumstances some individuals will be provided offender PHI without providing reasonable assurances or without obtaining the offender’s authorization. The following are a list of examples of individual or entities who may request PHI without providing reasonable assurances or the offender’s authorization:
1.Health care providers who have an ongoing treatment relationship with the offender and who would be considered a referring physician or providers who have a need to access information because the treatment that many have provided to an offender.
2.Health care professionals from the free world medical community, if the offender is being seen for emergency treatment and is still incarcerated.
3.In some instances, TDCJ administration may release offender PHI when required by law. For example, TDCJ may notify the Texas Department of Health (TDH) offender PHI if the offender has a communicable disease.
4.The release of HIV test results will conform to the requirements contained in Section 81.103 of the Health and Safety Code, Vernon’s Texas Codes Annotated.
D.A deceased offender’s personal representative may receive the health records to the same degree as the offender himself as long as an Affidavit of Personal Representative (Attachment B) is submitted. If the offender was not in custody of TDCJ when deceased, the personal representative must provide a copy of the death certificate.

1.If the offender is deceased, the personal representative can authorize the release of the offender’s health record to third parties, pursuant to Article 4495b, Sec. 5.08 and Article 5561h, Sec. 4(b)(4), provided a valid authorization is obtained.

2.At a minimum, the last 72 hours of the health record before the death of the offender shall be provided to the Justice of the Peace conducting an inquest. Written authorization is not required.


The unit health authority (TTUHSC)/management team (UTMB) must approve the sharing of information with personnel who have a need to know but are not included above.

III. Offender Authorization

A. A written authorization from the offender shall be required for all uses and disclosure of the offender’s PHI, except in the following instances:
1. Treatment;
2. Payment;
3. Healthcare Operations; or
4. As required by (State and Federal) law.

B. Health Records staff are responsible for releasing records and will only make the record available as outlined in this policy. The records may be further prohibited in writing by the unit health authority (TTUHSC)/management team (UTMB) or designee. All such prohibitions must be forwarded t the Division Director for Health Services.

C. Current offenders may review their health records at no cost. Such reviewed will be conducted on lather than the 15th calendar day after the date of the request is received and will not exceed thirty minutes in total time. Offenders that behave inappropriately (i.e., verbal or physical assaults, sexual misconduct; refusal to obey an order, etc…) during a scheduled medical record review will not be rescheduled for ninety (90) calendar days. A Health Services staff member will be present at all times while the offender is reviewing his health record. Only pencils will be provided to an offender while he is reviewing his record. Under no circumstances will an offender be allowed to review the health records of another offender.

D. An authorization form must be provided to authorized requestors and be signed by the offender or legal personal representative before copies are made and delivered.

Offender Copy Charges
First 50 pages $ .10 a page
Additional pages
and overhead charges
(see Attachment A) $ .10 a page plus personnel

These fees will not be applied in cases when the copies are used by community health care facilities and other governmental agencies for continuity of care purposes or in supporting an application for disability benefits.

E. Mental health records of an offender can be released to third parties if a signed authorization for the release of information is provided. State agencies and health care providers will not be charged a fee.

F. Inquires from the press must be referred to the TDCJ Public Information Office.

IV. Disclosure Log
Each facility health records department will maintain a log of all requests for release of information, including disclosures allowable by law. The log will include, but not be limited to, date of request, date of disclosure, individual/entity submitting request, name and number of offender, rationale for request, information released and format, i.e., pages 1-5 HSM-1.

V. Faxing Health Information
A health record may be sent by facsimile only when mailed copies will not meet time constraints or in the even of offender care emergencies and not for routine release of information to authorized third parties. An approved cover sheet must be used containing the confidentiality statement and a legend to the effect that any unauthorized use of the attached information is strictly prohibited and requesting that any data received in error be destroyed immediately and the fax operator notified of the error.

VI. Obtaining Offender PHI From TDCJ Hospital Galveston
All request for offender PHI generated at the TDCJ Hospital in Galveston must be directed to the Health Information Management Department. An HSA-107 form must be used and faxed to (409)772-9200.

VII. The responsible physician or his/her designee has access to information contained in the offender’s confinement record, when the physician believes this information may be relevant to the offender’s health status, by making a request to the facility administrator.

Release of information

NCCHC Standard P-H-02, Confidentiality of Health Records and I Information (essential)

NCCHC Standard P-H-03, Access to Custody Information (important)

Medical Practice Act

Texas Health and Safety Code

Consent to Medical Treatment Act

ACA Standard 4-4396 (Ref. 3-4377), Confidentiality (Mandatory)

ACA Standard 4-4415 (Ref. 3-4379), Inactive Records (Non-Mandatory)

Health Insurance Portability and Accountability Act