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Question: When our pathologist receives a tissue specimen, the ordering physician sometimes includes information about the patient鈥檚 family medical history. Is that information protected by HIPAA? Is it ok for the surgeon to share that information with the pathologist?

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Answer: Yes, a patient鈥檚 family medical history constitutes protected health information (PHI). The HHS Office for Civil Rights (OCR) says that a patient鈥檚 family medical history becomes PHI once it鈥檚 a part of the medical record.

鈥淲hen a covered health care provider, in the course of treating an individual, collects or otherwise obtains an individual鈥檚 family medical history, this information becomes part of the individual鈥檚 medical record and is treated as 鈥榩rotected health information鈥� about the individual,鈥� OCR says.

Crucial: Even if a family member is mentioned in a patient鈥檚 medical history, the patient 鈥� not the family member mentioned 鈥� retains the control over who the information can be shared with.

鈥淭hus, the individual (and not the family members included in the medical history) may exercise the rights under the HIPAA Privacy Rule to this information in the same fashion as any other information in the medical record, including the right of access, amendment, and the ability to authorize disclosure to others,鈥� OCR says.

Key: A covered healthcare provider may share PHI with another covered healthcare provider. They may even share a family member鈥檚 PHI with another provider in the course of caring for a patient. 鈥淔or example, an individual鈥檚 doctor can provide information to the doctor of the individual鈥檚 family member about the individual鈥檚 adverse reactions to anesthetics prior to the family member undergoing surgery,鈥� OCR reminds. You can use and disclose this type of PHI without written authorization or other agreement.

Psychotherapy notes are the only exception and require written authorization from the individual.