HIPAA (45 CFR Part 164) 164.510(b)(1) — Permitted uses and disclosures

What this control requires

Standard: Uses and disclosures for involvement in the individual's care and notification purposes (1) Permitted uses and disclosures. (i) A covered entity may, in accordance with paragraphs (b)(2), (b)(3), or (b)(5) of this section, disclose to a family member, other relative, or a close personal friend of the individual, or any other person identified by the individual, the protected health information directly relevant to such persons involvement with the individual's health care or payment related to the individuals health care. (ii) A covered entity may use or disclose protected health information to notify, or assist in the notification of (including identifying or locating), a family member, a personal representative of the individual, or another person responsible for the care of the individual of the individual's location, general condition, or death. Any such use or disclosure of protected health information for such notification purposes must be in accordance with paragraphs (b)(2), (b)(3), (b)(4), or (b)(5) of this section, as applicable.

In plain English

Standard: Uses and disclosures for involvement in the individual's care and notification purposes (1) Permitted uses and disclosures. In practice, this means you can prove you general 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(b)(1)) 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

• General. Document the trigger, the owner and the cadence.
• Information. Document the trigger, the owner and the cadence.
• Person. Document the trigger, the owner and the cadence.
• Other. Document the trigger, the owner and the cadence.
• Policy. Document the trigger, the owner and the cadence.
• Scope: management, individuals, notification, policy, i, accordance, section, uses.

Evidence to collect

• Policy Document. A signed and version-controlled policy / standard / procedure document.

Signed policy or standard documents the safeguard. Focus: Permitted uses and disclosures.

Common pitfalls

• Policies that no engineer has read; the version in Confluence drifts from the version that's actually being enforced.

Related controls in HIPAA (45 CFR Part 164)

• § 164.510(b)(5) — Uses and disclosures when the individual is deceased
• § 164.510(b)(3) — Limited uses and disclosures when the individual is not present
• § 164.510(b)(2) — Uses and disclosures with the individual present
• § 164.528(a) — Right to an Accounting of Disclosures of PHI
• § 164.502(h) — Confidential communications
• § 164.506(a) — Permitted uses and disclosures

References

• U.S. HHS Office for Civil Rights — HIPAA (45 CFR Part 164)
• Catalogue identifier: § 164.510(b)(1)

Topics: governance riskpolicy management