| PRIVACY POLICY AND
PROCEDURES |
Policy #: 2100.10 |
LSU Health Sciences Center New
Orleans
Date Effective: April 14, 2003 |
Table of Contents |
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Patient Information Policy
Patient’s Right of Access to and Obtain a Copy of
Their Protected Health Information
SCOPE:
All Louisiana State University (LSU) System health care
facilities and providers including, but not limited to
hospitals, physician practices, clinics, schools, etc. on
the LSU Health Sciences Center New Orleans Academic Campus.
Nota Bene: All LSU System health care facilities and
providers including, but not limited to hospitals, physician
clinics, schools, etc. on the LSU Health Sciences Center New
Orleans Academic Campus, are referred to in this policy as
LSUHSC-NO.
PURPOSE:
To provide guidance to the health care facilities and
providers affiliated with LSUHSC-NO on a patient’s right to
request access to and to receive a copy of their Protected
Health Information as required by the Health Insurance
Portability an Accountability Act, Standards for Privacy of
Individually Identifiable Health Information (HIPAA Privacy
Regulations), and any other applicable state or federal laws
or regulations.
POLICY:
All LSUHSC-NO health care facilities and providers must
provide patients with a right of access to inspect and
obtain a copy of their Protected Health Information about
the individual in a Designated Record Set of any LSUHSC-NO
health care facility or health
care provider.
DEFINITIONS:
Protected Health Information (also referred to as PHI) – for
purposes of this policy means individually identifiable
health information, that relates to the past, present or
future health care services provided to an individual.
Examples of Protected Health Information include medical and
billing records of a patient.
For the definition of "Designated Record Set" The term
"record" means any item,
collection, or grouping of information that includes
PHI and is maintained, collected, used or disseminated
by or for LSUHSC-NO.
The term "record" also includes patient information
originated by another health care provider and used by LSUHSC-NO to make decisions about a patient.
The term "record" includes tracings, photographs, and
videotapes, digital and other images that may be
recorded to document care of the patient.
Designated Record Set – is a group of records maintained by
or for LSUHSC-NO that is:
- The medical records and billing records about
individuals maintained by or for LSUHSC-NO.
- Any records used, in whole or part, by or for the
LSUHSC-NO to make decisions about individuals.
- Any record that meets this definition of Designated
Record Set and which are held by a HIPAA Business
Associate of LSUHSC-NO are part of LSUHSC-NO’s Designated
Record Set.
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Psychotherapy Notes – means notes recorded by a health
care provider who is a mental health professional
documenting or analyzing the contents of conversation
during a private counseling session or a group, joint
or family counseling session and that are separated
from the rest of the individual’s record.
Psychotherapy notes do not include: medication
prescription and monitoring, counseling session start
and stop times, the modalities and frequencies of
treatment furnished, results of clinical tests, and
any summary of the following items: diagnosis,
functional status, the treatment plan, symptoms,
prognosis, and progress to date.
Privacy Officer - person designated by LSUHSC-NO to be
the Privacy Official.
PROCEDURE:
| 1.0 |
Responsible Person. The
Privacy Officer shall be responsible for receiving
and processing requests for access by individuals
to inspect and obtain a copy of their Protected
Health Information in a Designated Record Set of
LSUHSC-NO. |
| 2.0 |
Designated Record Sets Subject
to Access by Patients.
A patient has a right of access to inspect and obtain a copy of PHI about the patient in the following designated record sets: |
| 2.1 |
All medical records maintained
by LSUHSC-NO that pertain to the patient making
the request; |
| 2.2 |
All billing records maintained
by LSUHSC-NO that pertain to the patient making
the request; and |
| 2.3 |
Any other records in
possession by LSUHSC-NO. |
| 3.0 |
Written Request for Access.
LSUHSC-NO may require patients to make a request
for access to inspect and copy their PHI to be in
writing, provided that the patient is informed in
advance of this requirement. See Attachment A. |
| 4.0 |
Deciding Whether to Grant a Patient Access to Their PHI. LSUHSC-NO must first decide whether to grant a patient
access to inspect and obtain a copy of their PHI in a
Designated Record Set. A patient does not have a right of
access to inspect and copy the following types of PHI: |
| 4.1 |
Psychotherapy notes; |
| 4.2 |
Information compiled in reasonable anticipation of, or
for use in, a civil, criminal, or administrative action or
proceeding; and |
| 4.3 |
Protected Health Information maintained by LSUHSC-NO
that is subject to the Clinical Laboratory Improvements
Amendments of 1988, 42 U.S.C. § 263a, to the extent the
provision of access would be prohibited by law; or |
| 4.4 |
Exempt from the Clinical Laboratory Improvements
Amendments of 1988, 42 C.F.R. §493.3(a) (2). |
| 5.0 |
Unreviewable Grounds for Denial of Access. In certain
circumstances, LSUHSC-NO may deny a patient access without
providing the individual an opportunity for review of the
decision to deny access. |
| 5.1 |
The PHI is not subject to the right of access as
provided in section 4.0 of this policy. |
| 5.2 |
If the Facility or Clinic is acting under the direction
of a correctional institution, then the LSUHSC-NO may deny,
in whole or in part, an inmate’s request to obtain a copy of
their PHI, if obtaining such copy would jeopardize the
health, safety, security, custody, or rehabilitation of the
patient or other inmates, or the safety of an officer,
employee, or other person at the correctional institution or
responsible for the transporting of the inmate; |
| 5.3 |
During the course of a patient’s participation in a
research program, the Facility or Clinic may deny access
provided that the patient agreed to the denial when
consenting to participation in the research program which includes treatment and the Facility or Clinic has informed the individual that the right of access will be reinstated upon the completion of the research. |
| 5.4 |
If the patient’s PHI was obtained from someone other
than a health care provider under a promise of
confidentiality, then the access requested would be
reasonably likely to reveal the source of the information;
or |
| 5.5 |
If the records are subject to the Privacy Act, 5 U.S.C.
A. § 552a, the denial of access under the Privacy Act would
be permissible if it meets the requirements of law. |
| 6.0 |
Reviewable Grounds for Denial.
LSUHSC-NO may
deny the patient’s request for the access on these grounds.
The patient must be provided with a right to have this
decision reviewed in the following circumstances: |
| 6.1 |
A licensed health care professional has
determined, in the exercise of professional judgment, that
the access requested is reasonably likely to endanger the
life or physical safety of the individual or another person; |
| 6.2 |
The PHI makes reference to another person
(unless the other person is a health care provider) and a
licensed health care professional has determined, in the
exercise of professional judgment, that the access requested
is reasonably likely to cause substantial harm to such other
person; or |
| 6.3 |
The request for access is made by the
patient’s personal representative and licensed health care
professional has determined, in the exercise of professional
judgment, that the provision of access to such personal
representative is reasonably likely to cause substantial
harm to the individual or another person. |
| 6.4 |
If a request for access to a patient’s PHI
is denied, then LSUHSC-NO must comply with either the
“Unreviewable Grounds for Denial of Access” or “Reviewable
Grounds for Denial of Access” and any other sections
concerning a denial decision that are applicable. |
| 7.0 |
Review of a Denial of Access.
If access is denied on a reviewable ground described in this policy, the patient has the right to have the denial reviewed by a licensed health care professional designated by the LSUHSC-NO to act as a reviewing officer and who did not participate in the original decision to deny. This designated reviewing officer must determine, within a reasonable period of time, whether or not to deny the access requested in accordance with the standards in the “Reviewable Grounds for Denial” section of this policy. LSUHSC-NO must promptly provide written notice to the individual of the determination of the designated reviewing official and take other action , as necessary, to carry out the designated reviewing official’s determination. |
| 8.0 |
Time Periods for Responding to Requests.
LSUHSC-NO must act on a request for access no later than 15
days after receipt of the request as follows: |
| 8.1 |
If LSUHSC-NO grants the request, in whole or
in part, it must inform the patient of the acceptance of the
request and provide the access requested; |
| 8.2 |
If LSUHSC-NO denies the request, in whole or
in part, it must provide the patient with the basis for the
denial in plain written language and, if applicable, how the
patient may exercise any available review rights; and a
description of how the patient can file any complaints
including the name, title, and telephone number or address
of the contact person; |
| 8.3 |
If LSUHSC-NO does not maintain the PHI that
is the subject of the request, and LSUHSC-NO knows where the
requested information is maintained, LSUHSC-NO must inform
the individual where to direct the request for access. |
| 9.0 |
Provision of Access if Granted. If LSUHSC-NO
provides a patient access, in whole or in part; |
| 9.1 |
LSUHSC-NO must within 15 days comply with the following
requirements:
| 9.1.1 |
Provide the patient access, including inspection and
copying, or both, of PHI about them in Designated Record
Sets. If the same PHI is contained in more than one
place or designated record set, the PHI need only be
provided once. |
| 9.1.2 |
The access must be in the form or format requested
by the patient, if it is readily producible, if not, in
a readable hard copy form or such other form or format
as agreed to by the LSUHSC-NO and the patient. |
| 9.1.3 |
LSUHSC-NO may provide the patient with a summary of
the PHI, in lieu of providing access to the PHI or may
provide an explanation of the PHI to which access has
been provided if:
| 9.1.3.1 |
If the patient agrees in advance to a summary or
explanation; and |
| 9.1.3.2 |
The patient agrees in advance to any fees
imposed by LSUHSC-NO for the summary or explanation. |
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| 10.0 |
Time and Manner of Access. LSUHSC-NO may
provide the access requested within the time
frames in this policy, including arranging with
the patient for a convenient time and place to
inspect or obtain a copy of the Protected Health
Information, or mailing a copy of the Protected
Health Information at the individual’s request.
LSUHSC-NO may discuss the scope, format, and other
aspects of the request for access with the patient
as necessary to facilitate the timely provision of
access. |
| 11.0 |
Fees for Copies. If the patient requests a
copy of the PHI LSUHSC-NO may impose a reasonable,
cost-based fee, not to exceed: |
| 11.0.1 |
One dollar ($1.00) per page for the first 25
pages; |
| 11.0.2 |
Fifty cents ($.50) per page for the next 26 –
500 pages; and |
| 11.0.3 |
Twenty-five cents ($.25) per pages for pages
greater than the first 500 copies. |
| 11.1 |
LSUHSC-NO may not impose a handling charge for
providing copies of his or her PHI. |
| 11.2 |
LSUHSC-NO may require the patient to reimburse
the Facility or Clinic for actual postage used in
mailing the PHI to the patient. |
REFERENCES:
45 C.F.R. § 164.524
LA R.S. 40:1299.96 |
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