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2017-01 Id of Unidentified Patients Model Policy

The document outlines a model policy for hospitals in New York State to assist in the identification of unidentified patients. It provides guidance on procedures for admissions staff, legal considerations under HIPAA, and collaboration with law enforcement and missing persons organizations. The policy emphasizes the importance of thorough identification efforts and documentation to ensure proper handling of unidentified individuals.

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2017-01 Id of Unidentified Patients Model Policy

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Identification of

Unidentified Patients
Model Policy
January 2017

New York State Division of Criminal Justice Services

80 South Swan Street, Albany, New York 12210

www.criminaljustice.ny.gov
Identification of Unidentified Patients – Model Policy

This model policy has been prepared to assist hospitals and medical facilities in developing
policies and procedures for missing and unidentified person’s investigations consistent with New
York State statutes and regulations. The information contained in this document is meant to
provide guidance and highlight points to consider when drafting a policy to meet the needs of a
particular community. This document is not intended to direct policy development nor does it
purport to contain the only acceptable practices. It is recommended that each hospital and
medical facility consult with its own legal advisor prior to adopting or amending a final policy
regarding identification of unknown patients.
Identification of Unidentified Patients – Model Policy

© January 2017, by the New York State Division of Criminal Justice Services. You are hereby
granted a non-exclusive license to use the enclosed materials for non-commercial use, and to
reproduce copy and/or distribute these materials for educational purposes. The Division’s
materials contained in this publication may be included in a non-commercial derivative work with
proper attribution to the New York State Division of Criminal Justice Services. These materials
may not be posted on a commercial or non-commercial Internet site without the prior written
permission of the Division. This non-exclusive license will be governed and construed in
accordance with the laws of the State of New York.

THE 2017 EDITION IS PUBLISHED BY THE:

New York State Division of Criminal Justice Services

Missing Persons Clearinghouse

80 South Swan Street

Albany, New York 12210

http://criminaljustice.ny.gov

VERSION January 2017

PRINTED IN THE UNITED STATES OF AMERICA

Identification of Unidentified Patients – Model Policy

Acknowledgements

The New York State Division of Criminal Justice Services (DCJS) acknowledges the extensive
work done by the following associations and agencies:

Albany Medical Center

John Heritage, Director of Security

Albany Memorial Hospital and Samaritan Hospital

John S. Janikas, MD, Director of Emergency Medicine

Greater New York Hospital Association

Laura Alfredo, Senior Vice President, Deputy General Counsel
Alison Burke, Vice President, Regulatory and Professional Affairs

New York City Health and Hospitals Corporation

Deirdre Newton, General Counsel

New York State Department of Health

Ruth Leslie Director, Division of Hospitals and Diagnostic & Treatment Centers
Karmel, Jonathan, Attorney - Bureau of House Counsel

New York State Division of Criminal Justice Services

Lisa Marie Coppolo, Associate Attorney
Cindy Neff, Program Manager, Missing Persons Clearinghouse
Raymond Neves, Case Manager, Missing Persons Clearinghouse

NYS Office of Alcoholism and Substance Abuse Services

Sara Osborne, Associate Attorney, Division of Legal Affairs

New York State Office of Mental Health

John Tremark, Chief Safety and Security Officer
Jessica R. Eber, Assistant Counsel

Samuel Stratton VA Medical Center

Alfred Articolo, Police Chief
John J. Nett, Emergency Manager
Identification of Unidentified Patients – Model Policy

I. PURPOSE

This policy is designed to provide guidance to emergency department staff in developing

procedures for the identification of unidentified patients that are admitted to the hospital.

II. POLICY:

When an unidentified patient is admitted to the Hospital, the admissions staff will
coordinate efforts to determine the unidentified patient’s identity.

III. DEFINITIONS:

A. Adequate identification: the ability of the patient or their escort to identify the
patient by name and date of birth or the patient has written identification such as
a driver’s license that contains that information.

B. Health Insurance Portability and Accountability Act of 1996 (HIPAA): the federal
Department of Health and Human Services (HHS) established national standards
for the security and privacy of health data. HIPAA privacy rules (45 CFR §
164.501 et seq.)

HIPAA allows disclosures to law enforcement in the following cases:

1. Court Order, Warrant, Subpoena, or Administrative Process: a Provider

may disclose information in response to a court order, warrant, subpoena
or other administrative process if certain conditions are satisfied. (45 CFR
§ 164.512(f)(1)(ii));

2. Identify Person: if law enforcement requests information to help identify or

locate a suspect, fugitive, material witness or missing person, a Provider
may disclose the following limited information: (a) name and address, (b)
date and place of birth, (c) social security number, (d) ABO blood type
and rh factor, (e) type of injury, (f) date and time of treatment, (g) date
and time of death, and (h) a description of distinguishing physical
characteristics. Other information related to the individual's DNA, dental
records, body fluid or tissue typing, samples, or analysis cannot be
disclosed under this provision, but may be disclosed in response to a
court order, warrant, or written administrative request. (45 CFR §
164.512(f)(2)). The disclosure must be in response to a request from law
enforcement, which may include a response to a "wanted" poster or
bulletin;

3. Death: a Provider may disclose information to notify law enforcement

about the death of an individual if the Provider believes the death may
have resulted from a crime;

1
Identification of Unidentified Patients – Model Policy

4. Fugitive: a Provider may disclose information to law enforcement to

identify or apprehend an individual who appears to have escaped from
lawful custody. (45 CFR § 164.512(j)(1)(ii)(B));

5. Medical Examiners and Coroners: a Provider may disclose information

about a decedent to medical examiners or coroners to assist them in
identifying the decedent, determining the cause of death, or to carry out
their other authorized duties. (45 CFR § 164.512(g)(1));

6. When considering disclosures to law enforcement, Providers should

consider the following:

a) If the law enforcement official making the request for information

is not known to the Provider, the Provider must verify the identity
and authority of such person prior to disclosing the information,
e.g., by requesting identification. (45 CFR § 164.514(h));

b) Except when required by law, a Provider should limit disclosures

to the minimum necessary. (45 CFR §§ 164.502(b), 164.514(d)).
When reasonable to do so, the Provider may rely upon the
representations of the law enforcement official (as a public officer)
as to what information is the minimum necessary for their lawful
purpose. (45 CFR § 164.514(d)(3)(iii)(A));

c) In all cases, a Provider should document the circumstances

surrounding the disclosure to law enforcement in the log for
accounting of disclosures as required by 45 CFR § 164.528.

C. New York State Division of Criminal Justice Services – Missing Persons

Clearinghouse: the Missing Persons Clearinghouse is responsible for providing
assistance to law enforcement agencies handling cases involving children,
college students and vulnerable adults who have gone missing. The
Clearinghouse maintains a 24/7 hotline at 800-346-3543.

D. National Center for Missing and Exploited Children: the leading nonprofit
organization in the U.S. working with law enforcement, families and the
professionals who serve them on issues related to missing and sexually exploited
children.

E. National Missing and Unidentified Persons System (NamUs): is a national

centralized repository and resource center for missing persons and unidentified
decedent records. NamUs is a free online system that can be searched by
medical examiners, coroners, law enforcement officials and the general public
from all over the country in hopes of resolving these cases.

F. National Crime Information Center (NCIC): is a computerized index of criminal-

justice information (i.e., criminal-record-history information, fugitives, stolen
properties, missing persons, unidentified bodies). Records contained in NCIC are
provided by federal, state, local, and foreign criminal-justice agencies, as well as
authorized courts. The index is available to federal, state, and local law-
enforcement and other criminal-justice agencies and is operational 24 hours a

2
Identification of Unidentified Patients – Model Policy

day, 365 days a year.

G. Unidentified Patient – when a patient is brought to the Emergency Department

without any identification and is not able to self-identify.

IV. PROCEDURE:

A. Upon the arrival of an unidentified patient:

1. The admission staff member will review the chart, personal belongings
and hospital records to determine if there is any information regarding
patient’s identity;

2. The admission staff member will notify the Information Desk so that
inquiries related to the unidentified patient are referred to the appropriate
staff as well as public safety personnel.

3. The patient will be registered into the hospital database with a last name
of Unidentified and a first name of either Male or Female which will be
dependent on their gender. Should there be multiple unidentified patients
admitted during a disaster or other such incident; they will be registered
as follows: Male Unidentified I, Male Unidentified II, etc. Detailed
physical descriptions should be entered into the database. This will
enable staff to more readily search for a patient should there be an inquiry
from the public or a family member.

B. If initial identification efforts fail, the admissions staff will contact hospital public
safety who will then contact the local law enforcement agency and request that a
police report be completed for an unidentified living/deceased person. The law
enforcement agency should be requested to enter the unidentified patient into the
National Crime Information Center (NCIC) database as an Unidentified Living
Person or an Unidentified Deceased Person (see attached NCIC Initial Entry
Report).

C. The admissions staff as well as public safety officers should also monitor
incoming e-mails and faxes from the New York State Missing Persons
Clearinghouse. The Missing Persons Clearinghouse routinely sends out posters
on active Missing Persons cases (Missing Child, Missing College Student and
Missing Vulnerable Adult). These posters for the most part contain a photo as
well as a description of the missing person. Additionally, a check of the following
websites should be conducted in an attempt to identify the patient:

New York State Division of Criminal Justice Services

Missing Persons Clearinghouse Children
http://criminaljustice.ny.gov//missing/#/

National Center for Missing & Exploited Children

http://www.missingkids.org/search

National Missing and Unidentified Persons Systems

http://namus.gov

3
Identification of Unidentified Patients – Model Policy

D. If there is a request from a law enforcement officer inquiring in regard to

unidentified patients, the hospital staff will conduct a search of the admissions
records to determine if there is a patient who may be a “possible match” for the
missing person. The “possible match” information should be provided to the
requesting law enforcement officer and every effort should be made to assist in
identifying the patient. Refer to HIPAA privacy rules (45 CFR § 164.501 et seq.):

1. Law enforcement verification standards include but are not limited to:

a) Official law enforcement agency email;

b) Official law enforcement agency fax;

c) In-person request of law enforcement officer with proper

identification;

d) Hospital Public Safety/Security personnel can also assist with law

enforcement verification;

e) Existing hospital policies.

2. Clinical information including but not limited to substance abuse and HIV
testing should not be released to law enforcement.

E. If finger printing services are needed, the admissions staff or public safety
personnel will contact the local law enforcement agency to request that
fingerprints of the unidentified patient be taken and processed:

F. If identification has not been made through the process of fingerprinting, the
admissions staff or public safety personnel shall make a referral to the Public
Information Officer to obtain a photograph of the patient as well as significant
facts that will help with identification. This information, along with the photograph,
will be submitted to local media outlets, (print and TV) for assistance in
identification. Consideration will be given to a specific locale if the patient’s point
of origin is known or suspected;

G. If the patient’s condition makes it impossible for a photograph to be taken, details

will be submitted for publication without the photograph;

H. If the patient is not identified within one week of publication of the photograph,
the photograph and significant facts shall be submitted for publication in a wider
area, until identification has been made.

I. A DNA sample can be collected by utilizing a DNA control kit and then forwarding
the sample to one of the regional centers for classification and possible
matching. Refer to attached list of regional centers;

J. When identification of a patient is made known, the Manager in the Admitting

Department is to be notified immediately so that the system and all records may
be updated;

4
Identification of Unidentified Patients – Model Policy

K. The elements necessary for identification are: patient’s name, address, date of
birth, social security # (if known), and next of kin;

L. The Manager in the Admitting Department is responsible for ensuring that

appropriate changes are made in the hospital’s registration system;

M. The Manager in the Admitting Department is responsible for notifying the Medical
Records department when it is deemed necessary to merge multiple patient
record numbers.

V. Applicable Health Laws:

A. HIPAA privacy rules (45 CFR § 164.501 et seq.);

B. MHL § 33.13. Clinical records; confidentiality;

C. § 164.510 Uses and disclosures requiring an opportunity for the individual to

agree or to object.

Note: The titles of those responsible for implementing this policy are generic and
should be modified to coincide with the staff titles for each individual hospital.

Attachments:
 NCIC Unidentified Data Collection Entry Guide (NCIC Initial Entry Report)
 DNA Regional Laboratories

5
NCIC Initial Entry Report
Message Key (MKE) (See Categories, page 2) Date

Unidentiﬁed Deceased (EUD) Unidentiﬁed Living (EUL)

Reporting Agency (ORI)
Unidentiﬁed Catastrophe Victim (EUV)

Body Parts Status (BPS) Body Parts Status (BPS) if incomplete body or skeleton, see body diagram page 7 for coding corresponding parts
N - Not Recovered D - Recovered Decomposed F - Recovered Fresh S - Skeletal
All 15 parts recovered - fresh (ALF) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
All 15 parts recovered - decomposed (ALD)
All 15 parts recovered - skeletal (SKL) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Sex (SEX) Race (RAC)

Male (M) Female (F) Asian or Paciﬁc Islander (A) American Indian/Alaskan Native (I) Unknown (U)
Unknown (U) Black (B) White (W)

Estimated Year of Birth Range (EYB) Estimated Date of Death (EDD) Date Body Found (DBF)

Approximate Height Range (HGT) Approximate Weight Range (WGT)

Eye Color (EYE) Hair Color (HAI)

Black (BLK) Green (GRN) Unknown (XXX) Brown (BRO) Sandy (SDY) Blue (BLU) Purple (PLE)
Blue (BLU) Hazel (HAZ) Multicolored (MUL) Black (BLK) Gray or Partially Gray (GRY) Green (GRE) Unknown or
Brown (BRO) Maroon (MAR) White (WHT) Red/Auburn (RED) Orange (ONG) Completely Bald
Gray (GRY) Pink (PNK) Blond/Strawberry (BLN) Pink (PNK) (XXX)

Scars, Marks, Tattoos, and other Characteristics (SMT) (See Checklist, page 8)

Fingerprint Classiﬁcation (FPC)* Originating Agency Case Number (OCA)

Miscellaneous (MIS) Information such as build, handedness, clothing description, hair description, and weather conditions at the time of death, place where
the individual was found, should be included. If more space is needed, attach additional sheet.**

* Fingerprints, if available, may be submitted electronically via the CJIS Wide Area Network or in hard copy to the FBI, CJIS Division,
Post Ofﬁce Box 4142, Clarksburg, West Virginia 26302-9929.
** All dental information should be recorded on the NCIC Unidentiﬁed Person Dental Report and entered into NCIC as supplemental information.
Blood Type (BLT)
A Positive (APOS) B Positive (BPOS) AB Positive (ABPOS) O Positive (OPOS) Unknown (UNKWN)
A Negative (ANEG) B Negative (BNEG) AB Negative (ABNEG) O Negative (ONEG)
A Unknown (AUNK) B Unknown (BUNK) AB Unknown (ABUNK) O Unknown (OUNK)

Circumcision? Footprints available? Body X-Rays available? Does the Unidentiﬁed Person Corrective Vision Prescription
(CRC) (FPA) (BXR) have corrected vision? (VRX)
(SMT)
Was Yes Full (F)
Was Not No Partial (P) Yes Glasses
Unknown None (N) No Con Lenses

Manner and cause of Death (CDA) Describe

Natural Causes (N) Suicide (S)

Accidental (A) Unknown (U)
Homicide (H)

Jewelry Type (JWT) (See Checklist, Jewelry Description (JWL) (See Checklist, page 20)
page 20)

DNA Proﬁle Indicator (DNA) DNA Location (DLO)

Yes
No

Medical Examiner/Coroner Agency Name and Case Number (MAN) Medical Examiner/Coroner Locality (MAL)

Medical Examiner/Coroner Telephone Number (MAT) Investigating Ofﬁcer and Telephone Number (MIS)

NCIC Number (NIC)

ERIE COUNTY DEPARTMENT OF CENTRAL POLICE P: 716-858-7408
SERVICES FORENSIC LABORATORY F: 716-858-7426

John Simich, Ph.D. – Laboratory Director

Public Safety Campus Building
45 Elm Street
Buffalo, New York 14203
E-mail: [email protected]

2017-01 Id of Unidentified Patients Model Policy

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2017-01 Id of Unidentified Patients Model Policy

Uploaded by

Identification of

New York State Division of Criminal Justice Services

THE 2017 EDITION IS PUBLISHED BY THE:

New York State Division of Criminal Justice Services

Missing Persons Clearinghouse

80 South Swan Street

Albany, New York 12210

VERSION January 2017

PRINTED IN THE UNITED STATES OF AMERICA

Albany Medical Center

Albany Memorial Hospital and Samaritan Hospital

Greater New York Hospital Association

New York City Health and Hospitals Corporation

New York State Department of Health

New York State Division of Criminal Justice Services

NYS Office of Alcoholism and Substance Abuse Services

New York State Office of Mental Health

Samuel Stratton VA Medical Center

This policy is designed to provide guidance to emergency department staff in developing

HIPAA allows disclosures to law enforcement in the following cases:

1. Court Order, Warrant, Subpoena, or Administrative Process: a Provider

2. Identify Person: if law enforcement requests information to help identify or

3. Death: a Provider may disclose information to notify law enforcement

4. Fugitive: a Provider may disclose information to law enforcement to

5. Medical Examiners and Coroners: a Provider may disclose information

6. When considering disclosures to law enforcement, Providers should

a) If the law enforcement official making the request for information

b) Except when required by law, a Provider should limit disclosures

c) In all cases, a Provider should document the circumstances

C. New York State Division of Criminal Justice Services – Missing Persons

E. National Missing and Unidentified Persons System (NamUs): is a national

F. National Crime Information Center (NCIC): is a computerized index of criminal-

day, 365 days a year.

G. Unidentified Patient – when a patient is brought to the Emergency Department

A. Upon the arrival of an unidentified patient:

New York State Division of Criminal Justice Services

National Center for Missing & Exploited Children

National Missing and Unidentified Persons Systems

D. If there is a request from a law enforcement officer inquiring in regard to

a) Official law enforcement agency email;

b) Official law enforcement agency fax;

c) In-person request of law enforcement officer with proper

d) Hospital Public Safety/Security personnel can also assist with law

e) Existing hospital policies.

G. If the patient’s condition makes it impossible for a photograph to be taken, details

J. When identification of a patient is made known, the Manager in the Admitting

L. The Manager in the Admitting Department is responsible for ensuring that

V. Applicable Health Laws:

A. HIPAA privacy rules (45 CFR § 164.501 et seq.);

B. MHL § 33.13. Clinical records; confidentiality;

C. § 164.510 Uses and disclosures requiring an opportunity for the individual to

Unidentiﬁed Deceased (EUD) Unidentiﬁed Living (EUL)

Sex (SEX) Race (RAC)

Approximate Height Range (HGT) Approximate Weight Range (WGT)

Eye Color (EYE) Hair Color (HAI)

Fingerprint Classiﬁcation (FPC)* Originating Agency Case Number (OCA)

Manner and cause of Death (CDA) Describe

Natural Causes (N) Suicide (S)

DNA Proﬁle Indicator (DNA) DNA Location (DLO)

NCIC Number (NIC)

John Simich, Ph.D. – Laboratory Director

Kori Gawrys, Ph.D. – QA Manager

ERIE COUNTY MEDICAL EXAMINERS OFFICE P: 716-961-7551

Christine Giffin – Chief County Toxicologist

MONROE COUNTY CRIME LABORATORY P: 585-753-3535

Marcia E. Bledsoe – QA Manager

MONROE COUNTY OFFICE OF THE MEDICAL EXAMINER P: 585-753-5923

Jeanne M. Beno, Ph.D. – Chief Toxicologist

Karen Mahoney – QA Manager

Joseph Avella, Ph.D. – Director of Forensic Toxicology

Timothy Hahn – QA Manager

NASSAU COUNTY OFFICE OF THE MEDICAL EXAMINER P: 516-572-5193

Pasquale Buffolino, Ph.D. – Laboratory Director

Karen Dooling – QA Manager (Biology)

Mark Gil-QA Manager (Latents)

NEW YORK CITY POLICE DEPARTMENT P: 718-558-8875