Patient Information Policy
Patient’s Right to Request an Amendment to 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 the LSUHSC-NO on a patient’s
right to request an amendment to their Protected Health
information as required by the Health Insurance Portability
and 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 to request an
amendment as required by the HIPAA Privacy Regulations. A
patient’s request for an amendment should be handled in
accordance with this policy and any applicable federal or
state laws or regulations. For purposes of this policy,
“amend” means a patient’s right to add to information in
their Protected Health Information (e.g. medical record)
with which he or she disagrees. “Amend” does not include
deleting or removing information from the content of a
medical record.
For purposes of this policy, "amend"
means a patient’s right to add to information in their
Protected Health Information (e.g. medical record) with
which he or she disagrees. "Amend" does not include deleting or removing
information from the content of a medical record.
LSUHSC-NO
acknowledges that under the HIPAA Privacy rule an individual
has the right to amend their Protected Health Information.
LSUHSC-NO understands that an individual may request that
information be deleted or may request the addition of
information into the record. When requesting an amendment,
LSUHSC-NO may deny an individual’s request for an amendment,
if it determines that the protected health information or
records that is the subject of the request:
(i) was not created by LSU, unless the
individual provides a reasonable basis to believe that the
originator of protected health information is no longer
available to act on the requested amendment;
(ii) is not part of a designated record
set;
(iii) would not be available for
inspection under section 164.524 (restriction on access to records) or;
(iv) is accurate and complete
DEFINITIONS:
Protected Health Information (sometimes 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 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; or
- Any records used, in whole or part, by or for
LSUHSC-NO to make decisions about individuals.
- Any record that meets this definition of
Designated Record Set and which is held by a HIPAA
Business Associate of LSUHSC-NO or part of LSUHSC-NO
‘s 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, videotapes, digital and other images
that may be recorded to document care of the
patient.
Privacy Officer - person designated by LSUHSC-NO to
be the Privacy Official and who is responsible for the
development and implementation of the patient privacy
policies and procedures.
PROCEDURE:
| 1.0 |
Requests for Amendment. |
| |
| 1.1 |
Patients have the right to request an
amendment to their Protected Health
Information for as long as it is maintained in
a Designated Record Set of LSUHSC-NO. |
| 1.2 |
LSUHSC-NO may require a patient to make a
request for an amendment to their Protected
Health Information to be in writing and that
this written request include a reason to
support the amendment. |
| 1.3 |
The Privacy Officer is the individual
identified by LSUHSC-NO to be responsible for
receiving and processing requests for an
amendment. |
|
| 2.0 |
Processing Requests for Amendments. |
| |
| 2.1 |
Upon receipt of the completed form for
request for amendment (See Attachment D),
[person designated by the facility or clinic]
shall review the request in consultation with
any individual, including the patient’s
physician or person who created the record
that [designated person] considers is
necessary to decide whether to accept or deny
the requested amendment in accordance with
this policy. |
| 2.2 |
If the requested amendment is accepted, it
is the responsibility of [designated person]
to process requests for amendment of patient’s
medical records. |
| 2.3 |
If the requested amendment is accepted, it is
the responsibility of [designated person] to
process requests for amendment of patient’s
billing records. |
| 2.4
|
LSUHSC-NO must act on the patient’s request
for an amendment no later than 60 days after
receipt of such a request. |
| 2.5
|
If LSUHSC-NO is unable to act on the request
for amendment within the 60 day time limit, it may
extend the time for such action by no more than 30
days, provided the patient or their personal
representative is provided with a written
statement of the reason for the delay and the date
LSUHSC-NO will complete its action on the request
(See Attachment C for sample letter). The time
period to respond to a request may only extend the
60 day time limit for handling requested
amendments for an additional 30 days. |
|
| 3.0 |
Deciding on Whether to Grant a Requested
Amendment. |
| |
LSUHSC-NO may deny a patient’s requested
amendment to their Protected Health Information,
if LSUHSC-NO determines that the Protected Health
Information that is the subject of the request:
| 3.1 |
Was not created by LSUHSC-NO, unless the
patient provides reasonable basis to believe that
the originator of the Protected Health Information
is no longer available to act on the requested
amendment; |
| 3.2
|
Is not part of the Designated Record Set of
LSUHSC-NO; |
| 3.3
|
Would not be available for inspection under
LSUHSC-NO ‘s policy for a Patient’s Right to
Access and Inspect Their Own Protected Health
Information; or |
| 3.4
|
LSUHSC-NO considers the patient’s Protected
Health Information to be accurate and complete.
|
| 3.5
|
If the requested amendment is granted, then
follow the section below on Granting Request for
Amendment, and if the request is denied, then
follow the section below on Denial of Requests for
Amendment. |
|
| 4.0
|
Granting Request for Amendment. |
| |
If a request for an amendment is accepted by
LSUHSC-NO, then LSUHSC-NO must do the following:
| 4.1 |
Make the Amendment. The amendment should be
made to the Protected Health Information or record
that is the subject of the request for amendment
by, at a minimum, identifying the records in the
Designated Record Set that are affected by the
amendment and appending, or otherwise providing, a
link to the location of the amendment. |
| 4.2
|
Inform the Patient. LSUHSC-NO must promptly
inform the patient that the amendment is accepted
and obtain the patient’s identification of or an
agreement to have LSUHSC-NO notify the relevant
person with which the amendment needs to be shared
as provided in this policy. (See Attachment A for
sample letter). |
| 4.3
|
Informing Others. LSUHSC-NO must make
reasonable efforts to inform and provide the
amendment within a reasonable time to the persons
identified by the patient as having Protected
Health Information about the patient and needing
the amendment, and persons and HIPAA Business
Associates that LSUHSC-NO knows have the Protected
Health Information that is the subject of this
amendment, or could foreseeably rely on such
information to the detriment of the patient. (See
Attachment B for sample letter). |
|
| 5.0 |
Denial of Request for Amendment.
|
| |
| 5.1 |
If a request for an amendment is denied by
LSUHSC-NO, then LSUHSC-NO must do the following:
| 5.1.1 |
Requests for amendment may be denied in
whole or in part. |
| 5.1.2 |
LSUHSC-NO must provide the patient or
their personal representative a written denial
within 60 days of the requested amendment.
(See Attachment E for sample letter). |
|
| 5.2 |
Content of Written Denial Statement. A written
denial statement from LSUHSC-NO must contain the
following:
| 5.2.1 |
the basis of the denial; |
| 5.2.2 |
a statement of the right of the patient or
their personal representative to submit a
written statement disagreeing with the denial
and how the individual may file such a
statement; |
| 5.2.3 |
a statement that, if the individual does
not submit a statement of disagreement, the
individual may request that LSUHSC-NO provide
the patient’s request for amendment and the
denial with any future disclosures of the
Protected Health Information that is the
subject of the amendment; and |
| 5.2.4 |
a description of how the patient may
complain to LSUHSC-NO pursuant to our
Complaint Policy or to the Secretary of Health
and Human Services and to file a complaint
with (office/physician) regarding the denial.
The description must include the name, or
title, and telephone number of the contact
person of LSUHSC-NO. |
|
| 5.3 |
Rebuttal Statement. LSUHSC-NO may prepare a
written rebuttal to the patient’s statement of
disagreement. If a rebuttal is prepared, a copy
must be provided to the individual who submitted
the statement of disagreement. |
|
6.0 |
Record Keeping. |
| |
LSUHSC-NO must identify the record or
Protected Health Information in the Designated
Record Set that is the subject of the denied
amendment and link the individual’s requested
amendment, the denial of the request, the
individual’s statement of disagreement, and
LSUHSC-NO’s rebuttal to the Designated Record Set.
|
| 7.0 |
Future Disclosures. |
| |
If a statement of disagreement has been
submitted, LSUHSC-NO must include the request for
amendment, the LSUHSC-NO denial, the statement of
disagreement, if any, and LSUHSC-NO rebuttal, if
any, in any subsequent record request for that
portion of the record to which the request for
amendment pertains. |
| |
| 7.1 |
If a statement of disagreement was not
submitted, LSUHSC-NO must include the request for
amendment and LSUHSC-NO denial, or an accurate
summary of such information, with any subsequent
record request for that portion of the record to
which the request for amendment pertains. |
|
| 8.0 |
Notice of Amendment from Others.
|
| |
If LSUHSC-NO is informed by another health
care provider of an amendment to an individual’s
protected health information, LSUHSC-NO must amend
the PHI in its Designated Record Set. |
REFERENCES:
45 C.F.R. § 164.526
|
