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Access to Designated Record Set: Difference between revisions
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Access to Designated Record Set (view source)
Revision as of 15:30, September 21, 2022
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Nebraska Medicine/UNMC designates the following records as its DRS: | Nebraska Medicine/UNMC designates the following records as its DRS: | ||
#'''Legal Medical Record'''. The Health Information Management Department (HIM) shall manage access to and amendment of the Legal Medical Record. Contents of the Legal Medical Record shall be approved by the Clinical Governance Committee. | #'''Legal Medical Record'''. The Health Information Management Department (HIM) shall manage access to and amendment of the Legal Medical Record. Contents of the Legal Medical Record shall be approved by the Clinical Governance Committee. | ||
#'''Billing Records'''. The DRS billing record includes all of the data elements required on the [ CMS-1500 form] or [ Health Care Financing Administration claim form (HCFA)]. The contents shall be approved by the Nebraska Medicine Chief Financial Officer for UNMC clinical operations using One Chart for patient care. | #'''Billing Records'''. The DRS billing record includes all of the data elements required on the [ CMS-1500 form] '''( form name and URL please)''' or [ Health Care Financing Administration claim form (HCFA)] '''(URL please)'''. The contents shall be approved by the Nebraska Medicine Chief Financial Officer for UNMC clinical operations using One Chart for patient care. | ||
#Any other record used in whole or in part by or for the covered entity to make decisions about Individuals. | #Any other record used in whole or in part by or for the covered entity to make decisions about Individuals. | ||
===Access to the Designated Record Set=== | ===Access to the Designated Record Set=== | ||
#Individuals have the right to inspect and obtain a copy of PHI about the Individual in their DRS for as long as the PHI is maintained in the DRS, subject to the limitations in | #Individuals have the right to inspect and obtain a copy of PHI about the Individual in their DRS for as long as the PHI is maintained in the DRS, subject to the limitations in Sections 13 and 14 below. | ||
#If the same record that is the subject of the request is maintained in more than one DRS or at more than one location, the department need only produce the record once in response to a request for access. | #If the same record that is the subject of the request is maintained in more than one DRS or at more than one location, the department need only produce the record once in response to a request for access. | ||
#'''Initiating a Request'''. Individuals shall complete a [Patient Access Request form (not yet approved)] to inspect and/or obtain a copy of the DRS, and submit it to HIM. HIM is responsible for the processing of all such requests. If the Individual completes an '''[Authorization for Release of Information Form, CON MR 0074] please advise (URL)'''and the recipient is the Individual or a third party designated by the Individual, this will be treated as a request for access. | #'''Initiating a Request'''. Individuals shall complete a [Patient Access Request form (not yet approved)] to inspect and/or obtain a copy of the DRS, and submit it to HIM. HIM is responsible for the processing of all such requests. If the Individual completes an '''[Authorization for Release of Information Form, CON MR 0074] please advise (URL)'''and the recipient is the Individual or a third party designated by the Individual, this will be treated as a request for access. | ||
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*[https://www.govinfo.gov/app/details/USCODE-2020-title42/USCODE-2020-title42-chap6A-subchapII-partF-subpart2-sec263a Clinical Laboratory Improvements Amendments of 1988, 42 U.S.C. § 263a] | *[https://www.govinfo.gov/app/details/USCODE-2020-title42/USCODE-2020-title42-chap6A-subchapII-partF-subpart2-sec263a Clinical Laboratory Improvements Amendments of 1988, 42 U.S.C. § 263a] | ||
*[https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-493 Clinical Laboratory Improvements Amendments of 1988, 42 C.F.R. § 493] | *[https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-493 Clinical Laboratory Improvements Amendments of 1988, 42 C.F.R. § 493] | ||
*[ CMS-1500 form] '''( form name and URL please)''' | |||
*[ Health Care Financing Administration claim form (HCFA)] '''(URL please)''' | |||
*[Patient Access Request form] (not yet approved) | *[Patient Access Request form] (not yet approved) | ||
*[Authorization for Release of Information Form, CON MR 0074] | *[Authorization for Release of Information Form, CON MR 0074] | ||
*[ Denial of Access to Medical Record/Billing Record] | *[ Denial of Access to Medical Record/Billing Record] | ||
*[ Correction/Amendment of Medical/Billing Information form] '''(URL please)''' it would help if this was a separate URL from the denial of access to medical record when it was saved on your web site | *[ Correction/Amendment of Medical/Billing Information form] '''(URL please)''' it would help if this was a separate URL from the denial of access to medical record when it was saved on your web site | ||
*[ Notice of Approved/Denied Request for Amendment form ' | *[ Notice of Approved/Denied Request for Amendment form ] '''(URL please)''' it would help if this was a separate URL from the denial of access to medical record when it was saved on your web site | ||
This page maintained and updated by [mailto:dpanowic@unmc.edu dkp]. | This page maintained and updated by [mailto:dpanowic@unmc.edu dkp]. | ||