G en. 205] 205 M ED I CAL RE CORDS C ONFI DE NT I AL I T Y OF M EDI CAL R ECORDS U ND E R M ARYL AN D L AW AND THE F EDERAL H E AL T H I NSURANCE P ORTABI LI TY AN D A CC OUN T AB I L I T Y A CT OF 1996 ( HI P AA)

D ece m ber18, 2003 M r . R ober tB aum C hai r, St at e Advis or

y C ounci lon Me d ica l P riv a c

y a n d C o n fide n tia lit

y D epar tm ent

of Heal th & M

entalH ygi ene Y ou have a s ked for our opi ni on conce r ni ng appl i cat i on of the f e d e ra l m e d ica l p riv a c yre g u latio n s th a t w e n t in to e f f e c t ea rlier th is y ear undert he H eal t h I ns ur ance Por t abi l i t yand A ccount abi l i t yA ct of 1996 ( “H I PA A ”). H I PA A cont ai ns a s el ect i ve pr eempt i on pr ovi s i on t hatpl ace s cu s t odi ans of m edi cal i nfor m at i on i n t he pos i t i on of det erm i ni ng w h etherfede r al orSt at e l aw governs di s cl os ur e of t hati nfor m at i on i n var i ous ci r cumst ance s . Y ou as k for gui dance on w hen the new fede r al r egul at i ons pr eemptexi s t i ng S t at e l aw con cerni ng con fi den t i al i t yof m edical recor ds. In o u r o p in io n , the re latio n sh ip o f H IP A A to e x is tin g S tate l aw s turns on the answ ers t o cert ai n q uest i on s: (1 ) F irst, o n e m u st d e ter m in e w h e th e r a c o n f lict a c tu a lly exi s t s – i.e ., i s the S t at e provis i on “con t rary ” t o H IPA A i n the sense th a t: ( a) i ti s i m pos sible to co m pl yw i t h bot h t he

re q u ire m e n ts of H IP A A a n d th e S ta te law ; or ( b) com p li ance w i th t he St at e l aw w oul d be i ncons i s t ent w i t h t he obj ect i ves of HI PAA ? I n m os ts i tuat i ons t her e w i l l be no conf l i ctbetw een St at e and f

eder al l aw and ther efor e no need to appl yt he H I PA A pr eempt i on p ro v isio n , alth o u g h th e H IP A A re g u latio n s m a y c re a te r e q u ire m e n ts a d d i t i o n a l t o t h o s e u n d e rS t a t e l a w.2 0 6 [8 8 O p . A tt ’y

Th is o pin ion

dis c us se s th eint e rp lay

of HI P AA and

theState 1 m ed i ca l re cords law . Other f ederal laws, such a s drugand alc ohol co n f id e nti a li ty

r e gu lati o n s , ma

y a ls o r e s tric t h e a lt

hin f o r mation disclosures in spec ific circum s t an ces. See42 U.S.C. §290dd-2. Simi larly , other State law s g overn disclosureof spec ific health care information. See, e .g. , Annotated Code of Mar yland, State Gover

nment Article, §10- 617 (disclosure of m edical information in the custody of State and local entities); Annotated Code of Ma ryland, Health-Gen eral Article (“HG” ), §18-337 ( disclosure of positive HIV status). F inally , the c on sti tution a l right of priva c y a lso may

re stric t di sc los urein s ome circ umstances. See Dr

. K v. B oard of Physician Quality Assurance , 98 Md. App. 103, 632 A.2d 453 (1993) , cert. denied, 334 Md. 18, 637 A.2d 1191, cert. denied, 513 U.S. 817 (1994). ( 2) Second, i f ther e appe ar s t o be a ge nui ne conf l i ctbetw een t he H I PA A r egul at i ons and St at e l aw , a cus t odi an of medi cal r ecor ds shou l d then co nsi der t he fo l l ow i ng qu est i on s:

( a ) D oe s t h e St a t e s t a tu t e f a l l u n d e rt he excl us i ons i n H I PA A for publ i c heal t h or r e g u l a t o r yr e p o r t i n g ? ( b) Is th e St at e s t atut e “mor e s t r i ngent ” than i t s HI PAA c o u n t e rp a r t ? ( c) H as t he Secr et aryof H eal t h and H um an Ser vi ces (“H H S”) det erm i ned thatt he S tate s ta tu te is e ith e r “ n e c e ss a ry ” to a c h iev e o n e o f

th e p e rm iss ib le S tate o b jec tiv e s liste d in H IP A A , o r th a t it add res ses cont rol l ed sub st ances? If t he answ er t o any of t hese qu est i on s i s yes , th e S tate p ro v isio n is n o t p re e m p ted b yH IP A A . If th e a n sw e r to a ll o f th e se q u e stio n s is no, t h e n HI P AA p r e e mp t s t h a ta s p e c to f S t a t e l a w. 1 I HI P AA E nact ed i n 1996, t he H I PA A s t atut e af fec t ed s ever al as pect s of th e h e a lth c a r e s y s te m . See Pub. L

. 104- 191, 110 St at

. 1936. For e x a m p l e , i tp r o v i d e d f

o rp o r t a b i l i ty ( i

. e. , tran sf e ra b ili ty ) o f

h e a lth i ns u ran ce cover age f

orpeopl e cha ngi ng empl oym ent

. A m aj or por t i on of H I PA A , t i t l ed “A dm i ni s t r at i ve Si m pl i fi cat i on, ” amendedG en. 205] 207

See<www .hhs.g ov/ocr/privac y summary .pdf>. 2 Health care cl earinghouse s include billing ser vices a nd simil ar 3 networks. 45 CF R 160.103. “He alth information,” in turn, is d ef i ned as “ any

information, 4 wh e ther o ral or

re c orde d in

any fo rm or me dium, t

hat: (1 ) is c re ate d b y a health c areprov ider, he a lth plan, public health authority , empl oyer, life i n s urer , school or univer sity , or health care clea ringhouse; and (2) relates to the past, present, or future physical

(continued...) the S o cial S ec u ri tyA ct w ith the p u rpo se o f in cre asin g h ea lth ca re s y s te m a c c o u n ta b ility a n d p re v e n tin g f ra u d a n d a b u s e . Id

. , T it le II, Subt i t l e F. T hatpor t i on of H IP A A r equi r ed H H S t o devel op a pr ogr am t o s i m pl i fyt he fi l i ng and paym entof hea l t h i ns ur ance c laim s b yp ro m o ti n g th e u se o f e lec tro n ic c laim s. In c o n c e rt w ith t hi s expans i on of el ectr oni c cl ai m s , H I PA A al s o compel l ed the d e v e lo p m e n t o f

sy ste m s to p ro tec t th e se c u rity a n d p riv a c y o f h e a lth car e i nfor m at i on. T o carr yout t hi s char ge, H H S adopt ed r egul at i ons g o v e r n i n g t h e c o n f

i d e n t i a l i t yo f

me d i c a l r e c o r d s , w hi c h b e c a me e f f e c tiv e A p ri l 1 4 , 2 0 0 3

. See 4 5 C F R P a rt s 1 6 0 a n d 1 6 4

. T h e H IP A A re g u la tio n s , a ls o re f e rr e d to a s th e “ P ri v a c yR u le ,” es t abl i s h nat i onal s t andar ds fort he pr ot ect i on of heal t h i nfor m at i on. A cc o rdin g to H H S , “[ a] m ajor g o al o f th e P ri v ac yR u le i s to a ssu re th a t in d iv id u a ls’ h e a lth in f o rm a tio n is p ro p e rlyp ro tec ted w h ile al l ow ing the fl ow of hea l t h i nfor m at i on neede d t o pr ovi de and p ro m o te h ig h q u a lityh e a lth c a re a n d to p ro tec t th e p u b lic’s h e a lth and w el l bei ng. ” O ffi ce of C i vi l R i ght s , D epart m entof H eal t h and H u m a n S e rv ic e s , S u m m a ry o f th e H IP A A P riv a c

y R u le ( M ay2003 r ev. ) atp. 1. 2 T h e H IP A A re g u latio n s a ttem p t to a c h iev e th a t g o a l in l anguage t hat i s bas ed on el abor at e defi ni t i ons of key t erm s . T he regul at i on s gov ern t he co nfidenti al i t yof “p rot ect ed h eal th inf o rm ati o n ” in th e c u stod yo f “ co v ere d en ti ti es.” T h e term “c o v ere d en ti ty ” e n c o m p a s s e s h e a lth p la n s , h ea lth ca re cl ear i nghous es , and pr ovi d ers w ho t r ans m i theal t h i nfor m at i on 3 e lec tro n ica lly

. 4 5 C F R § 1 6 0 .1 0 3

. “ P ro tec ted h e a lth in f o rm a tio n ” is i ndi vi dual l yi dent i fi abl e hea l t h i nfor m at i on m ai nt ai ned or t r ans m i t t ed i n any f

or m orm edi um . 4 5 C FR §164. 501. T he 42 0 8 [8 8 O p . A tt ’y

(...continued) 4 or mental he alth or condit ion of an individual; the provision of health ca re to a n individual; o r the past, pre sent or future pa y me nt fo r the prov isi on of he a lth c are to an in div idu a l. 45 CFR §160.103. See Kutzko, et al., HIPAA in Real Time: Practical Im plications 5 of t heFedera l Privac

yRu le , 51 Drake L

. Rev. 403, 418 (2003) ( arguing that th eHIPAA re gulatio ns e ssenti a lly “pa ss throu gh” thec on fi denti a lity restric tions from “covered entities” to “business associate s”). r egul at i ons do notr es t r i ctt he us e ordi s cl o su re of “de- i dent i fi ed” i nfor m at i on – i

. e. , h ea l t h i nfor m at i on t hatnei t heri dent i fi es nor p ro v id e s a re a s o n a b le b a s is to id e n tif ya n in d iv id u a l. See 45 CFR § § 1 6 4

. 5 0 2 (d), 16 4

. 5 1 4 (a), (b). I n es s ence , t he r egul at i ons pr ovi de that“[a ] cover ed ent i t ym ay notus e ordi s cl os e pr ot ect ed hea l t h i nfor m at i on, exce ptas per m i t t ed o r req u ir ed b y[th e H IP A A reg u lat ion s ]. 4 5 C F R § 1 6 4

. 5 0 2 (a). H IP A A r equi r es a cove r ed ent i t yt o ext end thes e r es t r i ct i ons by c o n tra c t to its “ b u sin e ss a ss o c iate s” w h o re c e iv e p ro tec ted h e a lth inf o rm ati o n to as sistin it s tr ea tm en t, p aym e n t, and h ea lth ca re oper at i ons . 45 C FR §164. 502( e) ( 1) , §164. 504( e)

. T he r emai nder 5 of the r egul at i ons det ai l s w hen and how pr ot ect ed hea l t h i nfo r m at i on m aybe di s cl os ed. I n gener al , a cove r ed ent i t ym us tnot i fya pat i ent of i t s p ri vacypr act i ces and mustobt ai n t he pat i ent ’ s author i zat i on fordiscl o s ur e of the pat i ent ’ s heal t h i nfor m at i on, unl es s t he di sclo su re i s fort r eatm ent , paym ent , orheal t h car e oper at i ons or o th e rw is e m e e ts s p e c if ie d e x c e p tio n s . See 45 C F R §§164. 506, 164. 508, 164. 512. T h e H IP A A re g u latio n s als o c o n f e r ce rta in a f

f irm a tiv e rig h ts on pat i ent s . A pat i entgener al l yhas a r i ghtt o i ns pectand obt ai n a copy of hi s or her m edi cal r ecor ds

. 45 C FR §164. 524. I n addi t i on, t he r egul at i ons pr ovi de s t andar ds and proc edur es foran i ndi vi dual t o s eek a n amendm entof a medi cal r ecor d. 45 C FR §164. 526. S u b jec t to a n u m b e r o f

e x c e p tio n s, a n in d iv id u a l is a lso e n tit led to a n a c c ou nt i ng of

di s c l os ur e s of hi s orhe rmedi c a l r e c or ds

. 45 CFR § 1 6 4 .5 2 8

.G en. 205] 209

Un i t e d S t at e s C o n s t i tut i o n , Art i c l eV I. 6 Th is rather c omp le x sch e me ha s g e nera te d s omec on fu sio n a s to 7 when federal or state law prevails. SeeBishop, The Final Patient Privacy Re gu lations u nd

e r th eHe alt

h I ns urance Po rta bility

an d A c c ou nta bility Act – Promoting Patient Privacy o r Public Confusion? , 37 Ga. L . Rev. 723, 724-28 (2003)

. II

H I P A A P ree m pt i on A . Feder al

P r eempti on Und e rth e Sup r e ma c yC l aus e of the fe der al C ons t i tut i on, w hen 6 C ongr es s pas s es a l aw t o r egul at e a p arti cul arfi el d, t he r es ul t i ng f e d e ra l la w m a y c o m p lete ly p re e m p t s tate law in se v e ra l w a y s. F irst, C ongr es s m ayexpr es s l ypr eempt s t at e l aw . Second, i n t he abs ence of expr es s p r e e mpt i o n , p r e e mpt i on i s i m pl i ed w hen C ongr es s i nt ends t hatfede r al l aw “occ upya gi ven fi el d. ” Thi r d, s t ate law w i l l be p re e m p te d w h e n it a c tu a lly c o n f lic ts w ith f

e d e ra l la w . C al i

f or ni a v. A R CA m . C orp . , 490 U

. S. 93, 100- 101 ( 1989)

. C onfl i ctbetw een sta te a n d f

e d e ra l la w is n o t p re su m e d , a n d w h e n e v e r p o ss ib le, s tate and feder al pr ovi s i ons s houl d be cons t rued i n a mannert o m ake th e m c o m p a tib le

. See R i ce v. Sa nta Fe E l evator C orp . , 33 1 U

. S. 218, 230 ( 1947) ; 84 O

p in io n s o f th e A tto rn e

y G e n e ra l 9 1 , 9 7 (19 9 9 ); buts ee T

he S up rem e C ou rt

, 19 99 T erm , 114 H arv. L

. R ev. 339 ( 2000) ( ar gui ng t hatt he pr es um pt i on i s not a str ong one and i s oft en v i o l a t e d )

. M o r e o v e r , e v e n wh e n i te x p r e s s l y p r e e mp t s s t a t e l a w, C on gress do es not a lw a y s do so en t i rel y . Inst ead, C on gress so m e tim e s s e lec tiv e lyp re e m p ts s tate law , p re se rv in g p a rt o f sta te la w b ya s a v in g s c la u s e . See 2 R otunda & N ow ak, Tre at is e on C ons t i t ut i onalLaw ( 3d ed. 1999) , §12. 1 atp. 200. H I PA A cont ai ns a s el ect i ve pr eempt i on pr ovi s i on w i t h r es pect t o me d i c a l r e c o r d c o n f i d e n t i a l i t y . I t e s t a b l i s h e s a g e n e r a l ru l e of fede r al pr eempt i on of s t at e l aw . H ow ever , H I PA A s aves s t at e l aw in se v era l w ay s: i t carv es o u t tw o m ajor are as in w h ich its ru les are i n a p p l i c a b l e ; i tp r o v i d e s f o ra d mi n i s t r a t i v e d e t e r mi n a t i o n o f t wo o th e r typ e s o f

e x c e p tio n s; a n d it d e f

e rs to sta te la w w h e n a sta te p rov isi on i s “more s t r i ngent ” than the corr es pondi ng fede r al p ro v isio n . In p ra c tice , the H IP A A re g u latio n s d o n o t ef f e c t a 7 w h o l e s a l e f

e d e r a l p r e e m p t i o n o f th e f i e l d o f m e d i c a l r e c o r d p r i v a c y, but r ather es t abl i s h a nat i onal fl oor of m edi cal pr ivac y p rot ect i on.2 1 0 [8 8 O p . A tt ’y See 65 Fed R eg. 82461, 82580 ( D ece m ber 28, 2000) ( D i s cus s i on of C o m m en ts, F inal P ri v ac yR u le). B . G ener al

R ule under H

I P A A : E xpr es s Statutor

y Pree mpti on Subj ectt o cert ai n exce pt i ons , C ongr es s expr es s l yadopt ed the gener al rul e thatt he H I PA A s t atut e, and any“s t andar d or im p le m e n tatio n sp e c if ica tio n ” a d o p ted u n d e r H IP A A “ sh a ll s uper s ede any contr ary pr ovi s i on of St at e l aw , i ncl udi ng a pr ovi s i on of St at e l aw that requi r es m edi cal orheal t h pl an r ecor ds

... t o be ma i n t a i n e d i n wr i t t e n r a t h e rt h a n e l e c t r o n i c f o r m. ” 4 2 U. S

. C. § 1 3 2 0 d -7 (a )( 1 ). C . Statutor

y E xcepti ons to H

I P A A P r eempti on C ongr es s des i gnat ed tw o are as of s t at e l aw , know n as “s t atut or y carve- out s , ” w her e H I PA A does not t rum p or ov erri de s t at e l aw . A not her s t atut or y pr ovi s i on pr es erves any s t at e l aw that is “ m o re s tr in g e n t” th a n th e f e d e ra l s ta n d a rd

. 1 . P u b li c H ea lt h I n one exce pt i on, H I PA A l i s t s a num ber of act i vi t i es c arr i ed outunders t at e publ i c hea l t h l aw s . I n par t i cul ar , C ongr es s pr ovi ded th a t “[ n ]o th in g in th is p a rt sh a ll b e c o n stru e d to in v a lid a te o r lim it” t he author i t y , pow er , orpr ocedur es es t abl i s hed underany l aw fort he foll ow i ng areas :

1

. t h e r e p o r t i n g o f

d i s e a s e o ri n

j u r y; 2. t he r epor t i ng of chi l d abus e; 3

. th e re p o rtin g o f

b irth o r d e a th ; 4

. p u b lic h e a lth su rv e ill a n c e ; 5

. p u b li c h ea lth inv esti g ati o n ; or 6. publ i c hea l t h i nt ervent i on. 42 U

. S. C

. §1320d- 7( b) ; 45 C FR §160. 203( c)

. U ndert hi s exce pt i on, s t at e and l ocal heal t h depart m ent s and ot heragenc i es m aycont i nue t o conducttr adi t i onal s ta t e publ i c hea l t h act i vi t i es w i t hout c o n f o r mi n g t h e i ra c t i v i t i e s t o HI P AA.G en. 205] 211

The re gulations define “health plan”to include employee w elfa re 8 benef it plans, HMOs, health insurers, and a varie ty of other enti t i es . 42 CFR §160.103. This saving s provision was designe d to g o into effe ct only if the 9 HIPAA privac y

standards w erepromulg ated by ag ency rulemakingby HHS, rath er than by

Congressional ac tion. Pub.L . 104-191, §264(c )(1)

. Since Congress did not ena ct a c omprehensive medical privacy law by statute, but instead deleg ated the task to HHS, the provision is effec tive. 2. St at e R e gul at or y R e por t i ng by H e al t h Pl ans A n o th e r sta tu to rye x c e p tio n e x p re ss lysa v e s ce rta in o th e r sta te r egul at or yr epor t i ng, l i cens ur e, and i nves t i gat oryact i vi t i es fr om fede r al pr eempti on. T hes e i ncl ude r equi r ement s t hata hea l t h pl an re p o rt o r p ro v id e a c c e ss to in f o rm a tio n f

o r: 1

. m a n a g e m e n t au d its; 2. fi nan ci al aud i t s; 3. pr ogr am m oni t or i ng and eva l uat i on; 4

. fa cil ityli ce n su re o r ce rt ifi ca ti o n ; or 5. i ndi vi dual l i cens ur e orcert i fi cat i on. 4 2 U .S .C . § 1 3 2 0 d -7 (c ); 4 5 C F R § 1 6 0 .2 0 3 (d )

. T h is a llo w s s tate h e a lth d e p a rtm e n ts a n d lice n sin g b o a rd s to c o n tin u e tra d iti o n a l sta te l i cens ur e and pr ogr amm at i c r evi ew an d eval uat i ve ac t i vi t i es c o n c e r n i n g h e a l t h p l a n s wi t h o u th a v i n g t o c o n f o r m t o HI P AA. 8 3. “M ore St ri ngent ” St at e L aw H IP A A a ls o p r o v id e s a n e x c e p tio n f o r a sta te la w th a t is “contr ary ” t o t he fe der al r egul at i ons i f the pr ovi s i on o f stat e l aw “i m pos es r equi r ement s , s t andar ds , ori m pl ement at i on s peci fi cat i ons t hatar e m or e s tr i ngent

t han” the compar abl e fe der al s t andar d. Pub. L

. 104- 191, §264( c) (2) in c o rp o ra tedb y re fer e n c e in 4 2 U. S

. C. §132 0 d -7(a )(2)(B ) (em p h asis ad d ed ); see al so 4 5 C F R § 1 6 0

. 2 0 3 (b). 9 H H S h a s f

les h e d o u t th is s a v in g s cla u se th ro u g h d e f in iti o n s in t he H I PA A r egu l at i ons . Fi r s t , t he r egul at i ons s ett he barhi gh for fi ndi ng a conf

l i ctbetw een H I PA A and s t at e l aw . T heydefi ne2 1 2 [8 8 O p . A tt ’y

“ c o n tra ry ” to m e a n e ith e r: 1 ) th a t an e n tityw o u ld f in d it i m p o ss ib le to c o m p lyw ith b o th th e sta te a n d f e d e ra l p ro v isio n s (“ im p o ss ib ili ty tes t”) ; o r 2 ) th a t th e p ro v isio n o f th e sta te la w sta n d s a s a n o b sta c le t o t he ful l purpos es and obj ect i ves of H I PA A ( “obs t acl e t es t ”)

. 45 C F R § 1 6 0 .2 0 2

. Si m i l ar l y , H H S has defi ned the t erm “more s t r i ngent ” t o m ean t hatt he s t at e l aw w oul d: r es t r i ct a d iscl os ur e perm i t t ed under HI P AA, g r a n ta n i n d i v i d u a l g r e a t e r a c c e s s t o t h e i n d i v i d u a l ’ s o wn heal t h i nfor m at i on, m or e s ever el yr es t r i ctt he s cope o rdur at i on of author i zed a cce s s by anotherper s on, r equi r e gr eat err ecor d- keepi ng, orgener al l ypr ovi de gr eat erpr i vacypr ot ect i on t o t he i ndi vi dual w ho i s t he s ubj ectof the r ecor d. 45 C

. F. R

. §160. 202. D . Adm inis tr ati v e Exce pti ons St at e l aw i s al s o notpr eempt ed i f the Secr et aryof H H S m akes cert ai n det erm i nat i ons . T hes e admi ni s t r at i ve exc ept i ons t o fede r al preem pti on fal l i nto tw o categori es. 1 . N ec essity A s t at e l aw s ur vi ves fede r al pr eempt i on i f the Secr et aryof H H S det erm i nes thatt he s t at e l aw i s “nec es s ary ” forone of t he f o llo w in g re a so n s:

1

. to p re v e n t f

ra u d a n d a b u se ; 2

. t o e n s u r e a p p r o p r i a t e s t a t e r e g u l a t i o n of in su ra n c e a n d h e a lth p lan s; 3

. fo r st ate rep o rt ing o n h ea lth ca re d eli v ery o r co sts, o r 4

. f o r o th e r p u rp o s e s . 42 U

. S. C

. §1320d- 7( a) ( 2) ( A ) ( i ) ; 45 C FR §160. 203( a) ( 1)

. U ndert he H I PA A r egul at i ons , a s t at e l aw pr ovi s i on i s “nec es s ary ” for“other purpos es ” w hen i ts erves a “c om pel l i ng need r el at ed t o publ i c hea l t h, s afe t y , orw el far e” a nd t he Secr et aryd et erm i nes t hatt he i nt rus i on i nt o pr i vacyperm i t t ed byt he s t ate l aw i s out w ei ghed byt he co m p ell ing n ee d that the law serv es. 45 C F R § 1 6 0

. 2 0 3 (a)(1)(iv). A ppl i cat i on of thi s “nec es s i t y ” exc ept i on i s di ffi cul t t o gauge beca us e, w hi l e t he re gul at i ons s et for t h pr ocedur es fora s t at e t o s eekG en. 205] 213
t he r equi sit e d et erm i nat i on fr om t he Secr et ary , theydo nots t at e a t i me t a b l e f

o rHH S t o ma k e t h a td e t e r mi n a t i o n . 4 5 CFR § 1 60. 204. It is n o t cle a r h o w p e rm iss iv e H H S w ill b e in a llo w in g c u rre n t sta te r egul at or yact i vi t i es that m aybe contr aryt o H I PA A t o cont i nue undert he “ne cessit y ” exce pt i on. T her efor e, fort he purpos e of a n i n i t i a l p r e e m p t i o n a n a l ys i s , w e w i l l n o ta s s u m e t h a ta “ n e c e s s i t y” e x c e p tio n w ill a p p ly. 2. St at e L aw A ddres s i ng C ont rol l ed Sub s t ances S tat e law is al so n o t p re em p ted if th e H H S S ec retary det er m i nes t hatt he s t at e pr ovi s i on ati s s ue “a ddr ess es contr ol l ed s ubs t ance s . ” 42 U

. S. C

. §1320 d- 7( a) ( 2) ( A ) ( i i )

. T he H H S r egul at i ons i nt erpr ett hi s exception t o covers i tuat i ons i n w hi ch the s t at e l aw “has as i t s pr i nci pal purpos e t h e regul at i on of the manufactur e, r egi s t r ati on, di s t r i but i on, di s pens i ng, orot hercontr ol of any contr ol l ed su b stan ces [as defi ned underfede r al ors t at e l aw ]

. ” 45 C FR §160. 203( a) ( 2)

. T hi s carves outs t at e l aw s us ed i n t he ci vi l or crim inal reg u lat ion o f co n tr o ll ed su b stan ce s. W h il e itap p ea rs un lik el yt hat the H H S S ecret aryw i l l be restri ct i ve in m aking t hese e x c e p ti o n d eterm ination s, a state m u st ap p lyto H H S fo r a d e te rm in a tio n . See 45 C FR §160. 204. III St at e M edi cal R ecor ds Law T h e M a ry lan d C o n f

id e n tialityo f

M e d ica l R e c o rd s L a w (“ S tate m edi cal r ecor ds l aw ”) appea r s i n A nnot at ed C o d e of M ary l and, H eal t h- G ener al A r t i cl e ( “H G ”) §4- 301 et s eq. T h a t la w s e ts f

o rth r e s t r i c t i o n s o n t h e d i s c l o s u r e o f me d i c a l r e c o r d s t h a t , l i k e t h e HI P AA r egul at i ons , ar e des i gned t o pr es erve the conf i dent i al i t yof m edi cal i nf o r ma t i o n p e r t a i n i n g t o i n d i v i d u a l s . Fo rp u rp o s e s o f t h e s t a tut e, “medi cal r ecor d” i s defi ned br oadl yand i ncl udes inf o r m at i on t r ans m i t t ed i n anyfor m , i f the i nfo rm at i on i s i dent i fi ed w i t h a p a r t i c u l a rp a t i e n t a n d r e l a t e s t o t h e h e a l t h c a r e o f t h a tp a t i e n t

. HG § 4 -3 0 1 (g ). U n d e r th e m e d ica l re c o rd s la w , a p a ti e n t h a s c e rta in rig h ts to i ns pectand obt ai n copi es of m edi cal r ecor ds , and t o have c or r ect i ons m ad e to th o se re co rds. H G § 4 -30 4

. T h e law req u ires h ea lth ca re pr ovi ders a nd ot her s t o pr es erve the conf i dent i al i t yof m edi cal r ecor ds , al t hough i tper m i t s di s cl os ur e w i t h t he w r i t t en author i zat i on2 1 4 [8 8 O p . A tt ’y

Th estatut ee mpl oys th eterm “pers on in intere st, ”whic h is 10 de fine d a s: (1) An adult on whom a he alth care

provider maintains a medical rec ord; (2 ) A pe rs on a

uth orize d to con se nt t o health ca re f or an adult consistent with the authority grante d; ( 3 ) Ad

u ly a p p o inte d p e r s o nal representative of a de cea sed per son; (4) (i) A minor , if

th emedical record concerns treatment to which the minor ha s th eright t o c o n s e nt a

n d h a s c o n sented under Title 20, Subtit le 1 of this article; or (i i ) A parent, gu ar d i an , custodian, or a repre sentative of the m inor designated by a court, in the discretion o f the attendingphy sician who provide d the treatment to the minor, as provided in §20- 102 or §20-104 of

this article; (5) I f paragraph (4) of this subsection does not apply

to a minor: (i) A parent of the minor, except if thepa rent’ s a uth ority to c on sent

to h e a lt h c ar e f

o r th e min o r h a s been s p e c if ic a lly li mi te d b y a c o urt o rd e r or a valid separation agreement entered into by the parents of the minor; or (i i) A pers on

a uth orize d to consent to h ealth ca

re f or the minor consistent with the authority grante d; or (6) An attorney appointed in writi ng by a person listed in paragraph ( 1), (2) , (3), (4), or (5) of this subsection. HG §4-301(k). ors t i pul at i on of t he pat i ent or another author i zed pe r s on. H G §§4- 10 302, 4- 303, 4- 306( b) ( 6) ( i i )

. I tal s o del i neat es t hos e l i m i t ed ci r cumst ance s i n w hi ch medi cal r ecor ds m ay o r m us tbe di s cl os ed w ith o u t th e p e rm is s io n o f th e p a tie n t. H G § § 4 -3 0 5 , 4 -3 0 6

. See gener al l y W ar nerv. Ler ner , 348 M d. 733, 738- 40 , 7 0 5 A

. 2d 1169 ( 1998)

. E ven w h en di s cl os ur e i s author i zed, t he M ary l and l aw r es t r i ct s t he us e and r edi s cl os ur e o f the r ecor ds byt he per s onG en. 205] 215

Th estatut estate s: 11 A p e rs onto who m a me dic a l re c ord is dis c los e d ma

y no t re dis c los etheme dic a l re c ord to any oth e r p e rs on

un le ss re dis c los ureis: (1 ) a uth orize d b y

thepers on

in intere st; (2) otherwise permitt ed by [the medical rec ords law] (3) permitted under [the law c oncer ning disclosure of c hild abuse re cords]; or (4) direc tory

information. re c e iv in g th e m . H G § 4 -3 0 2 (d ). S p e c ial re stric tio n s a p p lyto 11 m ent al heal t h r ecor ds

. H G §4- 307. Fi nal l y , t he St at e medi cal re c o rd s la w c re a tes liab ili tyru les a n d p e n a lti e s f o r a f a ilu re to compl yw i t h t he l aw . H G §§4- 308, 4- 309. IV P r e e m p tio n A n a ly sis A . I n G ener al M any pr ovi s i ons of t he fede r al H I PA A r egul at i ons an d the St at e medi cal r ec o rds l aw ar e ea s i l yhar m oni zed, es peci al l ygi ven th e p re su m p tio n a g a in st f in d in g a c o n f

lict be tw e e n f

e d e ra l an d sta te law that w o u ld resu ltin p ree m p tio n o f S tat e law

. B o th law s are sim il arly s tr u cture d

. E ac h reg u lat es d iscl o su re o f h ea lth ca re in f o rm a tio n b y h e a lth c a re p ro v id e rs . C om pa re 45 C FR §§160. 102, 160. 103 w ith H G §§4- 301( h) , 4- 302( a)

. E ach e s t abl i s hes a gene r al ru le p ro te c tin g th e c o n f id e n t i a lity o f

p a tie n t r e c o rd s . C om

pa re 45 C F R § 1 6 4 .5 0 2 (a ) w ith H G §4- 302( a)

. Pat i ent s ar e t o have r eady access t o thei r ow n records and a n ab i l i t y to am end t ho se r ecords. C om pa re 45 C FR §§164. 524, 164. 526 w ith H G § 4 -3 0 4 . A c c e ss is gr ant ed t o ot her s w ho pr ovi de anci l l aryt r eatm ent , paym ent , orot her h e a lth c a re o p e ra tio n s f

o r p a tie n ts

. C om

pa re 45 C FR §164. 506 w ith H G §4- 305( b)

. O t herdi s cl os ur es gener al l yr equi r e pat i ent a u th o ri z a tio n . C om

pa re 45 C FR §164. 508 w ith H G § 4 -3 0 3 . C e rta in l i m i t ed di s cl os ur es w i t houtpat i entauthor i zat ion , forr ecogni zed p u b lic p u rp o s e s , a re r e q u ir e d o r p e rm itte d

. C om pa re 45 CFR §164. 512 w ith H G § 4 -3 0 6 . B o th law s p u n ish v io latio n s w ith c iv il an d c ri m in a l p e n a ltie s . C om pa re 4 2 U

. S

. C

. § § 1 3 2 0 d- 5, 1320d- 6 w ith H G §4- 309.2 1 6 [8 8 O p . A tt ’y T here are al so si gn i fi cant di fferences betw een the t w o law s. H IPA A and i t s r egu latio n s r egu l at e on l ycert ai n “co vered en t i t i es”

– b a sic a lly , p ro v id e rs w h o e n g a g e in e lec tro n ic tra n sa c tio n s, h e a lth p la n s , a n d c la im s c le a ri n g h o u s e s . See 4 5 CF R § 1 6 0

. 1 0 2 ( a )

. By contr as t , t he St at e l aw , bypl aci ng r es t r i cti o n s on r edi s cl os ur e of re c o rd s , e x te n d s to a n y o n e w h o re c e iv e s m e d ic a l r e c o rd s . See HG §4- 302( g)

. T he St at e medi cal r ecor ds l aw i s m uch l es s det ai l ed than t he H I PA A r egul at i ons ; i t focus es s par i ngl y on w hetherdi s cl os ur es a re a u th o riz e d f

o r sp e c if

ic p u rp o se s. B yc o n tra st, H IP A A is e x tra o rd in a rily p re sc rip tiv e , sp e c if y in g th e m a n a g e m e n t o f h e a lth c a re in f o r m a ti o n a n d p e rso n n e l in sig n if ica n t d e tail. T h u s, w h ile M ary land law an d H IP A A , fo r th e m o st pa rt , h av e sim il ar d iscl o su re and n o n d i s c l o s u r e p r o v i s i o n s , HI PAA i s muc h mor e d e t a i l e d

. Y et t hos e addi t i onal H I PA A r equi r ement s do not nece s s ar i l ycr eat e a c o n f l i c twi t h t h e S t a t e l a w. B. Spe c i

f i c Appli c ati ons B ynece s s i t y , an opi ni on can n o t ans w eral l of the my r i ad ques t i ons t hat m ay ar i s e aboutt he r el at i ons hi p of the St at e medi cal r ecor ds l aw and the H I PA A regul at i ons . H ow ever , a r evi ew of se lec ted e x a m p les w ill ill u stra te th e a n a ly sis th a t m u st b e a p p lied to answ er tho se quest i on s. 1. R edi s cl os ure of

I nf orm at i on H IP A A c o n tro ls o n ly“ c o v e re d e n tit ies ,” w h ich a re h e a lth pl ans , cl ai m s cl ear ing h o u ses, an d p rov iders tha t tran sm iti nform at i on i n e l e c t r o n i c f

o r m. 4 5 CF R § § 1 6 0

. 1 0 2 , 1 6 0

. 1 0 3 I n d e e d , HI P AA re q u ire s a u th o riz a tio n f o r m s to sta te th a t, on c e in f o rm a tio n is d isc lo se d to a th ird p a rtyp u rsu a n t to a n a u th o riz a tio n , it s c on fi de nt i a l i t yi s no tpr ot e c t e d byH I PA A

. 45 CFR § 1 6 4 .5 0 8 (c )(1 )(v i). T h e S tate m e d ica l re c o rd s la w p rim a rily r egul at es heal t h car e fa ci l i t i es and pro v iders, and thei ragent s and em ploy ees, bu tal so precl ud es any per s on fr om r edi s cl os i ng m edi cal r ecor d i nfor m at i on, exce ptas author i zed byt he pat ient oras o th e rw is e p e rm itte d b yla w . H G § 4 -3 0 2 (d ). T h e tw o law s thu s ap p ea r t o b e in c o n sist en t. H o w ev er, M a r y l a n d ’ s r e d i s c l o s u r e p r o v i s i o n s u r v i v e s p r e e m p t i o n f o rt wo re a so n s. F irst, th e re stri c tio n s o n re d isc lo su re a re n o t co n tra ryto H I PA A , as i ti s noti m p o ssi bl e t o compl yw i t h bot h H I PA A and t hos e r es t r i ct i ons . N ordo t he r edi scl os ur e r es t r i ct i ons pos e an obs t acl e t o H I PA A , butr athers uppl ementi t

. T hus , undert heG en. 205] 217

The State medical rec ords law allows disclosure of a me dical 12 rec o rd o n l y

as per mitted by that law or “ as otherw ise provided by law.” HG§4 -3 02 (a)( 2) . It mi ght b eargue d th at th is p ro vis ion make s a p ermissive disclosure under HIPAA also a permissive disclosure under the State medical rec ords law. How ever , this c o n s truction would be at od ds wi th the state d po lic y that HIPAA set s minimum standards f or confide nt i al i ty

of medical rec ords and e xplicitly defers to “more string e nt”Statelaws . H IP A A re g u latio n s, th e M a ry lan d re d isc lo su re re stric tio n s a re n o t a S t a t e l a w “ c o n t r a r y ” t o HI P AA. Second, even i f t he M ary l and provi s i on coul d be cha r act er i zed as c o n tr aryto H IP A A , itsu rv iv e s p re em p ti o n b ec au se itis “m o re s t r i ngent ” than H IP A A

– t hati s , i tpr ovi des gr eat erpr ot ect i on for p ati en t i n fo rm ati o n . T h u s, the M ary land restri cti o n s o n red iscl o su re o f me d i c a l r e c o r d s a r e n o tp r e e mp t e d b yHI P AA. 12 2. H os pi t al Physi c i an D i s c i pl i nar y Repor ts and S u b p oen as M ary land law req u ir es a h o sp it al t o fil e a r ep o rt w ith the B o ard of Phy s i ci ans , t he St at e phy s i ci an l i cens ing boar d, w hen i thas d isc ip lin e d a p h y si c ia n . A n n o tate d C o d e o f M a ry lan d , H e a lth O ccupa t i ons A r t i cl e ( “H O ”) , §14- 413. T he r epor t m us ti ncl ude the r eas on for the d isc i pl i ne. O ft en thi s r epor ti nduces t he phy s i ci an l i cens i ng boar d t o i s s ue a s ubpoena t o t he hos pi t al and phy s i ci an for m edi cal r ecor ds

. U ndert he St at e medi cal r ecor ds l aw , t he hos pi t al and ph y sic ian m ustcom plyw i t h the subp oen a and dis cl ose t ho se r ecor ds t o t he boar d, w hetherornott he pati en t has author i zed or cons ent ed t o t he di s cl os ur e. H G §§4- 306( b) ( 2) , 4- 307( k) ( 1) ( vi ) 1. T he obl i gat i on t o compl yw i t h t hi s r epor t i ng r equi r ementand anys ubpoenas ar e notaff ect ed byH I PA A

. Fo r h ea lt h pl ans , t he S tat e rep o rt ing an d ind ividu al licen su re o r ce rt ifi ca ti o n ac ti v it ies are sta tu t ori l y carved out of the am bit of H IPA A , so M ary l and law is unaff ect ed and no f

ur t herpr eempt i on anal y s i s i s r equi r ed

. For pr ovi der s , H I PA A al l ow s di s cl os ur e of hea l th car e i nfor m at i on for heal t h over s i ghtact i vi t i es author i zed byl aw , i ncl udi ng l i cens i n g and d isci p li n aryac ti v it ies. 4 5 C F R § 1 6 4

. 5 1 2 (d).2 1 8 [8 8 O p . A tt ’y

An eight-pag e char

t list ing va

rious mandatory

disclosures under 13 Statelaw w a s c omp ile d b y the He a lth L aw Se c tio n of theMary land State Ba r Association and is available on theMSBA website. See <http://www.msba.org/sec_c omm/health/docs/req_cha rt.pdf>. T hus , t hes e di s cl os ur es fi tw i thi n t he cl as s of di s cl os ur es c o m p e lled u n d e r S tate la w a n d p e rm itt e d u n d e r H IP A A

. If S tate 13 l aw co m p el s di s cl os ur e of he al t h i nfor m at i on and H I PA A i s ei t her inap p li ca b le or pe rm issi v e re g ard ing the d iscl o su re, th en d iscl o su re m a n d a te d b yS ta te la w m a yc o n tin u e u n a b a te d

. 3 . P a t i e n t Au t h o r i z a t i o n F o r ms B ot h H I PA A and the St at e medi cal r ecor ds l aw al l ow for di s cl os ur es m ade w i t h t he author i zat i on of a pa t i entorot her“per s on i n i n t e r e s t

. ” Th e y e a c h s p e c i f y n e c e s s a r y e l e me n t s for an a u th o ri z a tio n to b e v a lid

. U nderH I PA A , an author i zat i on m us tcont ai n: 1) a des cr i pt i on o f th e in f o rm a tio n to b e d isc lo se d ; 2 ) i d e n tific a tio n o f th e p e rso n s to w hom t he i nfor m at ion is to be di s cl os ed; 3) i dent i fi cat i on of the per s on author i zed t o di s cl os e the i nfor m at i on; 4) a des cr i pt i on of the purpos e of the di s cl os ur e; 5) an expi r at i on dat e fort he author i zat i on; 6) a not e thatt he auth o ri zat i on m aybe r evoked; 7) a w arni ng t hat an y release d inf

o rm ati o n m ayb e b ey o n d the re ac h o f H IP A A ; 8) a s t at ement r egar di ng w hethert he Pr i vacy R ul e al l ow s benef i t s t o be condi t i oned on gr ant ing t he author i zat i on; 9) a s i gnatur e and da t e, and 10) i f the aut hor i zat i on i s m ade bya per s onal r epr es ent at i ve of th e p a tien t, th a t p e rso n ’s c a p a c ity

. 4 5 C F R § 1 6 4 .5 0 8 (c ). If h e a lth i nfor m at i on i s t o be us ed for m arket i ng and t he ent i t ydi s cl os i ng t he i nf o r ma t i o n wi l l r e c e i v e r e mun e r a t i o n i n c o n n e c t i o n wi t h t hat mar ke t i ng , t he a utho r i z a t i on fo r m m us t di s c l os e t ha tfa c t

. 45 CFR § 1 6 4

. 5 0 8 (a)(3)(ii ). T he St at e medi cal r ecor ds l aw s pecif i es fi ve el ement s foran author i zat i on: 1) t he documentm us tbe i n w r i t ing ; 2 ) i tm us tbe s i gned and da t ed byt he “ p erso n in i nt er es t ”; 3) i tm us ti ncl ude the n a m e o f th e d isc lo sin g p ro v id e r; 4 ) it m u st id e n tifyth e p a rtyto wh o m r e c o r d s a r e d i s c l o s e d ; a n d 5 ) i tmu s ts t a t e t h e p e r i o d o f t i me th e a u th o riz a tio n is v a lid . H G § 4 -3 0 3 (b ). T h e M a ry lan d law , w ith a coupl e of e xcep ti o n s , s et s a maxi m um l ength of one y earforan au tho ri za ti o n to b e v ali d

. H G § 4 -30 3 (b)(4 ).G en. 205] 219

F e e s f or re c ord s e arc he s and c op ie s of re c ords prov ide d by State 14 fac iliti es re gulated by

the Department of Health and Mental Hyg iene a re g overne d by

the Public Information Ac t. SeeHG §4-304( c)( 2)(i). In th is c a s e , th e p ro v isio n s a re slig h tlyd if f e re n t, bu t ea sily acc om m odat ed, and thus not “contr ary ” forpurpos es of pr eempt i on. A n a u th o riz a tio n th a t co n tain s th e n e c e ss a ryH IP A A e lem e n ts w ill a lso c o m p lyw ith th e M a ry lan d law if it c o n tain s a n e x p ira tio n d a te o f n o lo n g e r th a n o n e y e a r. T h e H IP A A re g u latio n s s p e c if ica lly al l ow for addi t i onal el ement s i n an author i zat i on for m , s o lon g as t heyar e noti ncons i s t entw i t h t he el ement s r equi r ed byH I PA A

. 45 C F R § 1 6 4

. 5 0 8 (b)(1 )(i i)

. T h e f ed era l w arn ing that an yred iscl o su re o f i nfor m at i on m aynotbe pr ot ect ed underfede r al l aw s houl d be t emper ed w i t h a s t at ement t hatw ron g ful r edi s cl os ur e i s pr ohi bi t ed u n d e r M a ryla n d la w . T he s peci fi c expi r at i on l i m i t i n M ary l and l aw and the l i m i t s on r edi s cl os ur e do notconfl i ctw i t h H I PA A and ar e both m or e s t r i ngent t han t he H IPA A regul at i on s. T hu s, H IPA A do es n ot pr eem pt tho se pr ovi s i ons . O f cour s e, an author i zat i on for m m us tcont ai n al l of the H IP A A e le m e n ts a s w e ll. 4. Fee s f

or C opi e s of

R e c or ds T h e M ary l and medi cal r ecor ds l aw governs fee s forr ecor ds pr ovi ded t o a per s on in interest“oranyot herauthor i zed pe r s on” w h o req u e s ts a co p yo f a m ed ical reco rd. H G § 4 -30 4 (c). In par t i cul ar , i tal l ow s pr ovi der s t o char ge a pr epar at i on and r etr i eval fee of up t o $15, a copy i ng fee of up t o 50 cent s per page, and ac tual pos t age a nd handl i ng fee s , all s ubj ectt o annual adj us t m entfor i nfl a t i o n a s me a s u r e d b yt h e Con s u me rPr i c e I n d e x . HG § 4- 3 0 4 (c)(3)-(4). 14 H I PA A s et s s om e l i m i t s on t he fe es t hatan i ndi vi dual m aybe c h a r g e d f

o ra c c e s s t o t h e i n d i v i d u a l ’ s o wn h e a l t h r e c o r d s . I ta l l o ws co v e r e d e n t i t i es t o i m pos e a r eas onabl e, cos t

- bas ed fe e, pr ovi ded that t he fe e i ncl u d es onl yt he cos tof copy i ng, pos t age, and pr epar at i on of a nys umm a r y( i f a s umm a r yi s r e qu e s t e d b yt he pa t i e nt )

. 45 CFR §164. 524(c)(4). H H S has i ndi cat ed thatt he cos tof r etr i evi ng or handl i ng i nfor m at i on i n r es pons e t o a pat i entr eques t forr ecor ds w as d e lib e ra te ly ex c lu d e d f

ro m th e lis t o f

p e rm is s i b l e c h a rg e s . See 65 F ed

. R eg . 8 2 4 6 1 , 8 2 5 5 7 (D ec em b er 2 8 , 2 0 0 0 ).2 2 0 [8 8 O p . A tt ’y

Be causeHIPAA contains no restrictions on charg es asse ssed 15 ag ainst non-patients for

retrie val and c o p yi n gof re cords, there is no c on fl ic t w ithMary

land law w ithre sp e c t to fe e s f or third pa rt y re qu e sts

. I tt hus appea r s t h at th er e i s a conf l i ctbetw een the M ary l and l aw and H I PA A w i t h r es pectt o the ch arge s t hatm aybe as s es s ed againsta pati ent w ho requ e sts a cop yof the pati ent’ s ow n records. T he M ary l and l aw al l ow s a provi der t o char ge an adj us t ed r etr i eval and handl i ng char ge of $15 orm or e; H I PA A , as cl ar i fi ed byt he H H S com m ent ary , does not

. T he M ary l and pr ovi s i on i s pr eempt ed by t he H IPA A regul at i on s, i nsofa r as i tapp l i es t o p at i ent r equ est s. 15 T he author i z a t i o n underM ary l and l aw t o char ge a 50- cent s - per - page in f latio n -a d ju sta b le c o p y in g f

e e a n d a c tu a l p o sta g e c o sts a p p e a rs to r emai n v ali d as not contr adi ct ed by , and perhaps fi l l i ng a voi d l eft o p e n u n d e r , HI P AA. 5. P arent al A c c es s t o R ecor ds of U nem anci pat ed M i nors H I PA A l ooks t o s t at e l aw r egar d ing p ar ent al acc es s t o t he r ecor d s of unemanci pat ed mi nor s . T he H I PA A r egul at i ons gi ve a par enti n s uch si tuat i ons t he ri ght t o vi ew t he mi nor ’ s r ecor ds t o t he extentt hat s t at e l aw al l ow s i t

. 45 C F R § 1 6 4. 50 2(g)( 3). T hu s, H IP A A d e f

e rs to sta te la w a n d re f

lec ts a n ya m b ig u ityf

o u n d in sta te l a w. T h e S tate m e d ica l re c o rd s la w ties th e a b ili tyo f a p a r e n t to exer ci s e r i ght s r egar di ng di s cl os ur e of a m i norchi l d’ s r ecor ds t o t he mi n o r ’ s c a p a c i t yu n d e rM a r y l a n d l a w t o c o n s e n tt o t r e a t me n t

. HG §4- 301( k) ( 4) , ( 5)

. Speci fi cal l y , a mi nor has t he s ame capac i t yas an ad u l tt o c o n s e n tt o t r e a t me n tf o rd ru g a b u s e , a l c o h o l i s m, v ener eal di s eas e, p regna ncy , contr ace pt i on, i nj ur i es fr om r ape ors exual offe ns e, and i ni t i al m edi cal s cr eeni ng of t he m i nori nt o a det ent i on cent er . H G §20- 102( c)

. A m i noratl eas t16 y ear s ol d has t he r i ght t o cons ent t o t r eatm ent for m ent al or emot i onal di s or der s . H G §20- 1 0 4

. T h e r e i s a s p e c i a l ru l e r e l a t e d t o t h e p r o v i s i o n o f a b o r t i o n . HG §20- 103. Fo r m ent al heal t h and abort i on s ervi ces , phy s i ci an p ro f e ss io n a l ju d g m e n t p lays a ro le in th e d e c isio n w h e th e r to d iscl o se in fo rm ati o n to the p are n t abo u t th e treatm en t of a m ino r. H G § § 2 0 -10 3 (c) an d 2 0 -10 4 (b). S in c e H IP A A e x p re ss lyd e f e rs to sta te la w o n th is su b jec t, th e re is n o p re e m p tio n is s u e .G en. 205] 221 6. R es earc h A compl ex ar ea i n H I PA A i nvol ves di s cl os ur es forr es ear ch p u rp o se s. T h e S tate m e d ica l re c o rd s la w d o e s n o t re g u late di s cl os ur e of m edi cal i nfor m at i on i f t he i nfor m at i on is not i nd i vidual l yi den t i fi able, or, al t ernat i vely , al l ow s r esear cher access w i t houtt he pat i ent ’ s pr i orauthor i zat i on i f the r es ear cher a c k n o w led g e s a d u tyn o t to re d isc lo se a n y in d iv id u a llyid e n tifia b le in fo rm ati o n an d co m p li es w ith insti tuti o n al rev iew b o ard req u ir em en ts. H G § § 4 -30 1 (g) a n d 4 -30 5 (b)(2 )(i ). H I PA A es t abl i s h e s d e t a i l e d s t a n d a r d s , l i n k e d wi th ot herfede r al r egul at i ons , fori ns t i tut i onal orpr i vacyr evi ew boar d w ai ver of t he n e e d f o r p a tien t au th o riz a tio n f o r th e d isc lo su re o f

h e a lth i nfo rm at i on . 45 C F R §§ 16 4. 50 1 an d 1 64

. 51 2(i ). H IPA A al so al l ow s cert ai n di s cl os ur es w i t houtpat i entauthor i zat i on orfor m al w ai ver fr om an i ns t i tut i onal r evi ew or pr i vacy boar d forpr epar at i on of r e s e a r c h p r ot oc ol s a nd fo rr e s e a r c h o n d e c ede nt s . 45 CFR § 1 6 4 .5 1 2 (i). In a d d iti o n , it p e rm its th e d isc lo su re o f p ro tec ted h e a lth i nfor m at i on w i thout cert ai n i dent i fy i ng i nfor m at i on pur s uant t o a “l i m i t ed dat a s etagr eement

. ” 45 C FR §164. 51 4

. I n t hi s r egar d, unl i ke St at e l aw , H I PA A s peci fi es ce r t ai n el ement s t hatm us tbe el i m i nat ed fr om t he heal t h i nform at i on t o m ake t he di s cl os ed in f o rm a tio n n o t id e n tifia b le. O n th is to p ic, in s o f a r a s H IP A A is m or e det ai l ed, fed era l l aw s uppl ement s , butdoes nots uppl ant , t he r e q u i r e me n t s o f

S t a t e l a w. V

C oncl usi on I n t hes e ea r l ys t ages o f H I PA A i m pl ement at i on, s i gni fi cant ques t i ons rega r di ng fede r al pr eempt i on ar e l i kel yt o ar i s e. T he r el at i ons hi p of H IP A A t o exi s t i ng St at e l aw s w i l l tur n on t he foll ow i ng analy si s: ( 1) Fi r s t , one mustdet erm i ne w het hera conf l i ctbetw een H I PA A and S tat e l aw actual l yexi s t s – i

. e. i s t he St at e pr ovi s i on “ c o n tra ry ” to H IP A A in th e se n se th a t:

( a ) i t i s i mpo s s i b l e t o c o mpl ywi t h bot h t he re q u ire m e n ts of H IP A A a n d th e S ta te law ; or2 2 2 [8 8 O p . A tt ’y ( b) compl i ance w i t h t he St at e law w o u ld be i ncons i s t ent w i t h t he obj ect i ves of HI PAA ? I n m os ts i tuat i ons t her e w i l l be no conf l i ctbetw een St at e and f

eder al l aw an d t her efor e no nee d t o appl yt he H I PA A pr eempt i on pr ovi s ion , al t hough H I PA A m ayeff ect i vel ys uppl ementt he re q u ir e m e n ts o f

S ta te la w . ( 2) I f there appea r s t o be a ge nui ne conf l i ctbetw een the H I PA A r egul at i ons and St at e l aw , a cus t odi an of medi cal r ecor ds shou l d then co nsi der t he fo l l ow i ng qu est i on s:

( a) D oes t he St at e s t atut e fa l l undert he excl us i ons i n H I PA A for publ i c heal t h or r e g u l a t o r yr e p o r t i n g ? ( b) I s t he St at e s t atute “m or e s t r i ngent ” than i t s HI PAA c o u n t e rp a r t ? ( c) H as the H H S Secr et arydet erm i ned that th e S tate sta tu te is e ith e r “ n e c e ss a ry ” to a c h iev e o n e o f

th e p e rm iss ib le S tate o b jec tiv e s liste d in H IP A A , o r th a t it add res ses cont rol l ed sub st ances? If t he answ er t o any of t hese qu est i on s i s yes , th e S tate p ro v isio n is n o t p re e m p ted b yH IP A A . If th e a n sw e r to a ll o f th e se q u e stio n s is no , t h e n HI P AA p r e e mp t s t h a ta s p e c to f S t a t e l a w. J. Jo sep h C u rran , Jr. A t t or ney G ener al C

. Fr eder i ck R y l and A s s is t ant At to rn e y G ener al R o b e rt N . M c D o n a ld C hi ef C ouns el O pi ni ons and A dvi ce