HIPAA (45 CFR Part 164) 164.510(b)(3) — Limited uses and disclosures when the individual is not present

What this control requires

Limited uses and disclosures when the individual is not present. If the individual is not present, or the opportunity to agree or object to the use or disclosure cannot practicably be provided because of the individual's incapacity or an emergency circumstance, the covered entity may, in the exercise of professional judgment, determine whether the disclosure is in the best interests of the individual and, if so, disclose only the protected health information that is directly relevant to the persons involvement with the individual's care or payment related to the individual'`s health care or needed for notification purposes. A covered entity may use professional judgment and its experience with common practice to make reasonable inferences of the individual's best interest in allowing a person to act on behalf of the individual to pick up filled prescription, medical supplies, X-rays, or other similar forms of protected health information.

In plain English

Limited uses and disclosures when the individual is not present. 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(b)(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.
• 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.
• Notification. Document the trigger, the owner and the cadence.
• Scope: management, notification, policy, uses, payment, disclosure.

Evidence to collect

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

Signed policy or standard documents the safeguard. Focus: Limited uses and disclosures when the individual is not present.

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.

• NIST SP 800-53 Rev. 5 CM-3(1) — Automated Documentation, Notification, And Prohibition Of Changes
• BSI C5:2020 SP-01 — Documentation, communication and provision of policies and instructions
• 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)

• § 164.510(b)(2) — Uses and disclosures with the individual present
• § 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
• § 164.510(a)(3) — Uses and Disclosures for Facility Directories in Emergency Circumstances
• § 164.510(b)(4) — Uses and disclosures for disaster relief purposes

References

• U.S. HHS Office for Civil Rights — HIPAA (45 CFR Part 164)
• Catalogue identifier: § 164.510(b)(3)

Topics: governance riskpolicy management