CMS Pub. 100-01, ch. 6, § 140.1

Program (CMS)

(Rev. 1, 09-11-02)

A. Disclosure of Survey Information of the Joint Commission on Accreditation for

Hospitals (JCAH), American Osteopathic Association (AOA), or any other National

Accreditation Organization

The CMS may not disclose any accreditation survey made and released by the JCAH,

AOA or other national accreditation organization except as prescribed by regulations.

Accreditation letters and accompanying Recommendations and Comments prepared by

the JCAH, AOA or other national accreditation organization for the provider's

accreditation survey are confidential and exempted from public disclosure.

A copy of the provider's most recent accreditation survey may be disclosed with the

provider's authorization to any authorized representative, employee or agent of CMS for

official use only in connection with the Medicare sample validation or substantial

allegation survey program.

B. Disclosure of Information About Hospitals, Skilled Nursing Facilities, Home Health

Agencies, and Independent Laboratories

Information about a hospital, skilled nursing facility, or home health agency, as well as

information about independent laboratories, providers of outpatient physical therapy

(rehabilitation and public health agencies and clinics) and portable X-ray suppliers, may

be disclosed without the authorization of the institution or organization when such

disclosure is required for the proper performance of the duties of:

• An officer or employee of the Department;

• An officer or employee of a contractor; or

• An officer or employee of a State agency when necessary to carry out their duties

under State law in the licensing or approving of hospitals, skilled nursing

facilities, home health agencies, or independent laboratories, etc.

Information obtained in the provider certification process is not to be disclosed to those

not included in the above three categories, except as indicated in §140.3 below.

However, information that a particular institution is participating in the program may be

released; and information indicating the specialties for which title XVIII payment may be

made for services of a particular independent laboratory may be released. This

information is usually available from the Directory of Medical Providers and Suppliers of

Services published by the Government Printing Office.

C. Contractors' Disclosure to Third Parties

Disclosure to third parties for program purposes of information about identifiable

physicians and other suppliers who are natural persons is governed by the same

restrictions and procedures as disclosure about named beneficiaries to third parties for

program purposes. (See §50 of this chapter.)

Information about unidentifiable individuals or about providers or corporate entities (e.g.,

clinics or independent laboratories), is not exempt from disclosure by section 1106 and

regulations at 42 CFR, Part 401. However, it is not to be disclosed by third parties to

which information is disclosed for program purposes.

If the information the contractor discloses to third parties for program purposes is solely

information that does not identify, or make identifiable, individuals (e.g., aggregate

statistics or records on providers and other corporate entities) the following sample letter

is to be used instead of the letter in §50B of this chapter.

Sample Letter from Contractor to Third Party

Dear

We are prepared to make available to your organization certain CMS records so that

(state reason).

However, before making these records available to you, we must point out that by

law all information derived in the administration of the Social Security Act is

subject to the provisions of the Freedom of Information Act, which exempts from

disclosure certain categories of records. In order to assure that no records held

confidential under the Freedom of Information Act are disclosed, you must agree to

meet the following conditions before we make any social security records available

to you:

• 1. Any information we supply you will be used only for the specific

purpose intended and for no other purpose.

• 2. All employees having access to this material will be instructed as to its

confidential nature.

• 3. An official of your company will assume responsibility for ensuring that

the information is not revealed to any other party.

• 4. You must return the material to us as soon as you have finished the job,

and you may not retain copies.

• 5. We must have a letter from a responsible official in your office agreeing

to these conditions and assuming responsibility for carrying them out.

Upon receipt of this letter from your organization, we will make available to you

the CMS records you requested.

Sincerely yours,