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1. RowanSOM strives to prevent the intentional or inadvertent misuse of patient names, identities and medical records; to report criminal activity relating to identity theft and theft of services to appropriate authorities; and to take steps to correct and prevent further harm to any person whose name or other identifying information is used unlawfully or inappropriately. 
2. In response to the growing threats of identity theft in the United States, Congress passed the Fair and Accurate Credit Transactions Act of 2003 (FACTA), which amended a previous law, the Fair Credit Reporting Act (FCRA).  This amendment to FCRA charged the Federal Trade Commission (FTC) and several other federal agencies with promulgating rules regarding identity theft.  On November 7, 2007, the FTC, in conjunction with several other federal agencies, promulgated a set of final regulations known as the “Red Flags Rule”.  The Red Flags Rule became effective January 1, 2008, however, the FTC has deferred its enforcement of the rule pending limiting legislation in Senate.  On December 18, 2010, the Red Flag Rule Program Clarification Act of 2010 was signed by the President of the United States which clarifies the type of creditor that must comply with the rule and limits the circumstances under which creditors are covered.  These creditors must comply by December 31, 2010.  The new law covers creditors who regularly, and in the ordinary course of business, meet one of three general criteria. They must:
   1. obtain or use consumer reports in connection with a credit transaction;
   2. furnish information to consumer reporting agencies in connection with a credit transaction; or
   3. advance funds to -- or on behalf of -- someone, except for funds for expenses incidental to a service provided by the creditor to that person.
3. The Red Flags Rule regulations require entities with accounts covered by the Red Flags Rule regulations, including universities, to develop and implement a written Identity Theft Prevention Program (hereinafter, the “Program” or the “Identity Theft Program”) for combating identity theft in connection with certain accounts.  The Program must include reasonable policies and procedures for detecting, preventing and mitigating identity theft and enable the entity with covered accounts to:
   1. Identify relevant patterns, practices, and activities, dubbed “Red Flags”, signaling possible identity theft and incorporate those Red Flags into the Program; Detect the Red Flags that the program incorporates;
   2. Respond appropriately to any Red Flags that are detected to prevent and mitigate identity theft; and
   3. Ensure the Program is updated periodically to reflect changes in risks.  

    VII.  POLICY

This policy outlines the Identify Theft Prevention Program of RowanSOM which encompasses not only financial or credit accounts, but any RowanSOM account or database for which RowanSOM believes there is a reasonably foreseeable risk to RowanSOM, faculty, staff, patients, constituents or customers from identity theft.

RowanSOM will implement and maintain an Identify Theft Prevention Program to assure compliance with federal law and RowanSOM policies preventing, detecting and mitigating possible identity theft of its patients, customers, clients and its constituents.

All RowanSOM employees and individuals working on behalf of RowanSOM in any capacity (including Board members, medical staff, business associates, independent contractors, and volunteers) will conduct themselves and their activities in a manner so as to protect the sensitive information, such as personal identifying information that may be used to defraud or aid identity theft as required by federal law and in conformance with RowanSOM policies.

1. Requirements:
   1. RowanSOM’s Identity Theft Prevention Program will consist of the following elements:
      1. a detailed policy that specifically addresses this identity theft prevention program that includes reasonable policies and procedures to detect or mitigate identity theft and enable RowanSOM to:
         1. Conduct a survey to identify and detect potential and relevant “Red Flags” (See FTC’s examples of red flags, EXHIBIT A) and incorporate the results of the survey into the program.
         2. Respond appropriately to red flags to prevent and mitigate identity theft.
         3. Identify the Process of Establishing a Covered Account - this generally happens automatically when a patient makes an appointment and information is collected as part of that registration process.
         4. Maintain access control to covered account information.
         5. Address credit card payments.
         6. Establish training requirements of employees and vendors, and
         7. Ensure the Program is updated periodically to reflect changes in risks.
   2. RowanSOM is required to adopt detailed processes and procedures (refer to EXHIBIT B) that will address the following identity theft concerns:
      1. Refusal to provide or lack of identification.
      2. Process to follow if there are signs of possible identity theft.
      3. Process to follow when an employee reasonably believes identity theft has occurred or may be occurring; include in the process to notify the Compliance Officer to advise of the potential identity theft. (Refer to EXHIBIT C for sample form).
      4. Process to follow when identity theft is alleged by a patient; include the process to notify the Compliance Officer to advise of the potential identity theft. (Refer to EXHIBIT D for sample letter).
      5. Process to follow when identity theft is suspected to have occurred (including notification to law enforcement, customers, patients, etc.). (Refer to EXHIBIT E for sample letter).
      6. Appropriately responding to detected Red Flags.
      7. Notification from law enforcement and customers, patients, etc., when identify theft is suspected or known to have occurred (Refer to EXHIBIT F for sample letter).
      8. Coordinating with area health care providers.
      9. Process for entering patient accounts affected by identity theft on hold.
      10. Prevention and mitigation of identity theft.
      11. Recoveries from suspect.
      12. Accounting for inappropriate disclosures of protected health information.
      13. When patient misidentification occurs. (Refer to EXHIBIT E).
      14. Documenting identity theft or patient misidentification.
      15. Updating the policy and procedures
   3. Education and Training
      1. The Chief Audit, Compliance & Privacy Officer, or designee, will provide general training to refresh the University workforce regarding the Identity Theft Prevention Program, policies and procedures and the Red Flags Rule regulatory requirements.
      2. Training of appropriate staff as determined by the Dean, Chief Operations Officer & Chief Audit, Compliance & Privacy Officer.
      3. The Department of Human Resources will ensure that all new members of the workforce partake in Identity Theft Prevention training within one month after the person joins the workforce.
      4. School or Unit Privacy Liaisons will ensure retraining of the workforce whose functions are affected by a material change in the policies and procedures within a reasonable period after the change becomes effective.
      5. Training provided will be appropriately documented and the documentation will be maintained by RowanSOM Privacy Liaisons for a minimum of six (6) years or as specified by the New Jersey State Record Retention Schedule.
   4. Updating The Program
      1. On an annual basis, as part of the Office of  Compliance and Corporate Integrity’s monitoring plan, the Program will be re-evaluated to determine whether all aspects of the Program are up to date and applicable.  This review will include an assessment of which accounts and/or databases are covered by the Program, whether additional Red Flags need to be identified as part of the Program, whether training has been implemented, and whether training has been effective.  In addition, the review will include an assessment of whether mitigating steps included in the Program remain appropriate, and/or whether additional steps need to be defined.
2. Responsibilities:
   1. The Vice President for Human Resources shall be responsible for communicating and enforcing the above policy as it relates to all RowanSOM employees.
   2. The Chairpersons and Dean shall be responsible for communicating and enforcing the above policy as it relates to persons involved in patient contact.
   3. The Clinical Affairs and Deans, shall be responsible for communicating and enforcing the above policy as it relates to persons involved in Faculty Practice and patient care. The Director of Purchasing or his or her successors shall be responsible for communicating and enforcing the above policy as it relates to contractors, agents, business associates, and others associated with or supporting RowanSOM.
   4. Monitoring and Evaluation
      1. The Office of Compliance and Corporate Integrity Compliance Committee is the governing body for the evaluation and monitoring of the Identity Theft Prevention Program.
      2. The program is subject to periodic audit.
      3. The Chief Audit, Compliance & Privacy Officer and RowanSOM Chief Operating Officer (COO or their designee) will review the program at least annually.
      4. The Chief Audit, Compliance & Privacy Officer and Investigators are responsible for investigating and reporting on allegations of non-compliance with RowanSOM Identity Theft Prevention Program policies.
      5. Privacy Liaisons, under the direction of the Chief Audit, Compliance & Privacy Officer, RowanSOM COO, and Investigators may be asked to conduct investigations of non-compliance with RowanSOM Identity Theft Prevention Program policies.
3. Documentation
   1. Documentation evidencing implementation of the Identify Theft Prevention Program, including complaints, training, sanctions, auditing, etc., will be maintained for a minimum of six (6) years or the time period specified by New Jersey State Retention Schedules, whichever is longer.
4. Enforcement: 
   1. The Deans, Vice Presidents and Directors, with the assistance of the Department of Human Resources, will enforce the sanctions appropriately and consistently.

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1. Purpose
   1. The purpose of the Identify Theft Red Flag and Security Incident Reporting Procedure is to provide information to assist individuals in (1) detecting, preventing, and mitigating identity theft in connection with the opening of a “covered account” or any existing “covered account” or who believe that a security incident has occurred and (2) reporting a security incident.
2. Background
   1. Security Incident 
      1. The American Recovery and Reinvestment Act (ARRA) requires that any organization that owns computerized data that includes personal information shall disclosure any breach of security of the system following discovery or notification of the breach in the security of the system to whose unencrypted personal information was, or is reasonably believed to have been, acquired by an unauthorized person.
   2. Red Flag Rules
      1. In 2003, the U.S. Congress enacted the Fair and Accurate Credit Transaction Act of 2003 (FACT Act) which required the Federal Trade Commission (FTC) to issue regulations requiring “creditors” to adopt policies and procedures to prevent identify theft.
      2. In 2007, the Federal Trade Commission (FTC) issued a regulation known as the Red Flag Rule. The rule requires “financial institutions” and “creditors” holding “covered accounts” to develop and implement a written identity theft prevention program designed to identify, detect and respond to “Red Flags.”
      3. The Red Flag Rule has been implemented by the Federal Trade Commission (FTC) on August 1, 2009.
3. Definitions
   1. Covered Account
      A covered account is a consumer account designed to permit multiple payments or transactions.  These are accounts where payments are deferred and made by a borrower periodically over time such as a  fee installment payment plan.
   2. Creditor
      A creditor is a person or entity that regularly extends, renews, or continues credit and any person or entity that regularly arranges for the extension, renewal, or continuation of credit. Examples of activities that indicate a college or university is a “creditor” are:
      1. Offering institutional loans to faculty or staff;
      2. Offering a plan for payment of patient services rather than requiring full payment
   3. Personal Information
      This information includes an individual’s first name or first initial and his or her last name in combination with any one or more of the following data elements, when either the name or the data elements are not encrypted or redacted: Social Security Number, driver’s license, health insurance information, medical information, or financial account number such as credit card number, in combination with any required security code, access code, or password that would permit access to an individual’s financial account.
   4. Red Flag
      A red flag is a pattern, practice or specific activity that indicates the possible existence of identity theft.
   5. Security Incident
      A collection of related activities or events which provide evidence that personal information could have been acquired by an unauthorized person.
4. Identification of Red Flags
   1. Broad categories of “Red Flags” include the following:
      1. Alerts – alerts, notifications, or warnings from a consumer reporting agency including fraud alerts, credit freezes, or official notice of address discrepancies.
      2. Suspicious Documents – such as those appearing to be forged or altered, or where the photo ID does not resemble its owner, or an application which appears to have been cut up, re-assembled and photocopied.
      3. Suspicious Personal Identifying Information – such as discrepancies in address, Social Security Number, or other information on file; an address that is a mail-drop, a prison, or is invalid; a phone number that is likely to be a pager or answering service; personal information of others already on file; and/or failure to provide all required information.
      4. Unusual Use or Suspicious Account Activity –such as material changes in payment patterns, notification that the account holder is not receiving mailed statement, or that the account has unauthorized charges;
      5. Notice from Others Indicating Possible Identify Theft–such as the institution receiving notice from a victim of identity theft, law enforcement, or another account holder reports that a fraudulent account was opened.
5. Detection of Red Flags
   1. Detection of Red Flags in connection with the opening of covered accounts as well as existing covered accounts can be made through such methods as:
      1. Obtaining and verifying identity;
      2. Authenticating employees or patients;
      3. Monitoring transactions
   2. A data security incident that results in unauthorized access to an employee’s or patient’s  account record or a notice that an employee or patient  has provided information related to a covered account to someone fraudulently claiming to represent RowanSOM or to a fraudulent web site may heighten the risk of identity theft and should be considered Red Flags.
6. Response to Red Flags
   1. If an employee or patient detects fraudulent activity (a red flag) or if an employee or patient claims to be a victim of identity theft, RowanSOM will respond to and investigate the situation.  If the fraudulent activity involves protected health information (PHI) covered under the HIPAA security standards, RowanSOMwill also apply its existing HIPAA and ARRA security policies and procedures to the response.  If potentially fraudulent activity (a red flag) is detected by an employee or patient of RowanSOM: 
      1. The employee/patient should gather all documentation and report the incident to his or her designated compliance officer.
      2. The compliance officer will determine whether the activity is fraudulent or authentic based upon the evidence presented.
      3.  If the activity is determined to be fraudulent, then RowanSOM should take immediate action.  Actions may include:
         1. Cancel the transaction
         2. Notify appropriate enforcement agencies
         3. Notify the affected employee or patient
         4. Notify affected physician(s)
   2. If an employee or patient claims to be a victim of identity theft:
      1. the employee/patient should be encouraged to file a police report for identity theft if he/she has not done so already
      2. the employee/patient patient should be encouraged to complete the ID Theft Affidavit developed by the FTC, along with supporting documentation  www.ftc.gov/bcp/edu/resources/forms/affidavit.pdf.
   3. If following investigation, it appears that the employee/patient has been a victim of identity theft, RowanSOM will promptly consider what further remedial action/notifications may be needed under the circumstances.
7. Security Incident Reporting
   1. An employee who believes that a security incident has occurred, shall immediately notify their designated compliance officer or call the hotline at 1-855-431-9967. 
   2. Service Providers
8. RowanSOM remains responsible for compliance with the Red Flags Rule even if it outsourced operations to a third party service provider. The written agreement between RowanSOM and the third party service provider shall require the third party to have reasonable policies and procedures designed to detect relevant Red Flags that may arise in the performance of their service provider’s activities. The written agreement must also indicate whether the service provider is responsible for notifying only RowanSOM of the detection of a Red Flag or if the service provider is responsible for implementing appropriate steps to prevent or mitigate identify theft.
9. Training
   1. All employees who process any information related to a covered account shall receive training following appointment on the procedures outlined in this document.  Refresher training may be provided annually.
10. References:   
    1. Fair and Accurate Credit Transactions Act of 2003 (FACTA)
    2. American Medical Association

ATTACHMENT C

IDENTITY ALERT FORM

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