164.510(a)(3)·medium·Component: Privacy RuleWhat this control requires
Emergency circumstances. (i) If the opportunity to object to uses or disclosures required by paragraph (a)(2) of this section cannot practicably be provided because of the individual's incapacity or an emergency treatment circumstance, a covered health care provider may use or disclose some or all of the protected health information permitted by paragraph (a)(1) of this section for the facility's directory, if such disclosure is: (A) Consistent with a prior expressed preference of the individual, if any, that is known to the covered health care provider; and (B) In the individual's best interest as determined by the covered health care provider, in the exercise of professional judgment. (ii) The covered health care provider must inform the individual and provide an opportunity to object to uses or disclosures for directory purposes as required by paragraph (a)(2) of this section when it becomes practicable to do so.
In plain English
Emergency circumstances. In practice, this means you can prove you information management-level controls on a defined cadence.
Why it matters
HIPAA non-compliance is a strict-liability matter: OCR civil monetary penalties are assessed per-record per-violation (up to USD 1.9 million per identical-violation calendar year as of 2024), and willful neglect can trigger criminal referral.
What an auditor looks for
HHS OCR investigators and SOC-2+HIPAA auditors look for the specific 45 CFR § citation, whether the safeguard is required vs addressable (and if addressable, the documented decision), the implementation specification, the workforce member responsible, and the records that show it runs.
Within Privacy Rule, the assessor will trace your implementation back to the catalogue reference (§ 164.510(a)(3)) and look for objective evidence on the latest two assessment cycles.
How to implement
Policy Management
Docs. Keep each policy in version-controlled Markdown alongside the code that implements it; ship a signed PDF snapshot at each annual review and link the SHA into the SoA.
Operational checklist
- Information. Document the trigger, the owner and the cadence.
- Facility. Document the trigger, the owner and the cadence.
- Policy. Document the trigger, the owner and the cadence.
- Uses. Document the trigger, the owner and the cadence.
- Disclosures. Document the trigger, the owner and the cadence.
- Scope: management, policy, i, section, directory, uses, b, ii.
Evidence to collect
- Policy Document. A signed and version-controlled policy / standard / procedure document.
Signed policy or standard documents the safeguard. Focus: Uses and Disclosures for Facility Directories in Emergency Circumstances.
Common pitfalls
- Policies that no engineer has read; the version in Confluence drifts from the version that's actually being enforced.
How it maps to other frameworks
Computed from shared tags, control component and key-operation subjects — handy when you are reconciling controls across an audit.
- BSI C5:2020 SP-01 — Documentation, communication and provision of policies and instructions
- NIST SP 800-53 Rev. 5 CP-7(2) — Accessibility
- ISO/IEC 27001:2022 A.5.5 — Contact with authorities
- SOC 2 (2017 TSC) CC2.3 — External Communication on Internal Control Matters
- NIST SP 800-171 Rev. 3 3.13.15 — Session Authenticity
Related controls in HIPAA (45 CFR Part 164)
- § 164.512(a) — Uses and disclosures required by law
- § 164.510(b)(2) — Uses and disclosures with the individual present
- § 164.514(d)(5) — Minimum Necessary - Other content requirement
- § 164.512(k)(6) — Uses and disclosures for specialized government functions - Providing public benefits
- § 164.512(h) — Uses and disclosures for cadaveric organ, eye or tissue donation
- § 164.512(k)(3) — Uses and disclosures for specialized government functions - Protective Services
References
- U.S. HHS Office for Civil Rights — HIPAA (45 CFR Part 164)
- Catalogue identifier:
§ 164.510(a)(3)
Topics: governance riskpolicy management