Access to Designated Record Set: Difference between revisions

==Procedures==

===UNMC Records in 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 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 unusual circumstances have delayed handling the request, HIM may notify the Individual in writing that an extension (not to exceed 21 days) from the original date UNMC received the complete request is necessary and shall provide the reasons the extension is necessary. The extension notice must state the date by which access or copies will be available. (See the [Extension Notice] provided with this policy.)

#'''If copies of the records are requested, HIM/UNMC must produce the requested copies within 30 days of the date UNMC received the request. No extension of this date is permitted without the patient’s consent.'''

#*If PHI is maintained electronically in one or more DRS for such Individual and the Individual requests an electronic copy of their information, UNMC must provide such information to the Individual in the form and format requested by the Individual, if it is readily producible. If HIM/UNMC cannot readily produce it as requested by the Individual, then such information must be produced in a form and format as mutually agreed by the Individual and HIM/UNMC. If HIM/UNMC and the Individual cannot agree on an electronic form and format, then HIM/UNMC must provide a hard copy option to fulfill the access request.

#*Inspection will generally be during normal business hours of HIM, unless special circumstances are present. Consult the [mailto:privacy@nebraskamed.com Privacy Officer] if the patient requests to inspect the records or obtain a copy before or after normal business hours.

#At the patient’s request, HIM will mail a copy of the records in the format requested to the patient at the address designated on the request form. If requested by the patient, HIM will email a copy of the records to the patient. If the patient requests the records be sent by unsecured email, HIM will confirm that the patient understands the information could be intercepted before complying with the request.  

#If the patient requests in advance an explanation or summary of the information and agrees to pay the fee for preparing the summary, HIM shall prepare the summary and provide it to the patient.

#The patient will be notified when the records are available for inspection or that a copy is available for pick-up or mailing/e-mailing. The total cost to the Individual for producing and mailing/e-mailing a copy should be included. Payment for copying/mailing/e-mailing the requested records will be collected prior to the time the records are released. Patients generally have access to their own medical information during and after treatment via the One Chart | PATIENT portal. The One Chart | PATIENT portal is a secure online application that allows patients to view portions of their medical and billing record. Patients may give others proxy access to their portal account. Parents may obtain limited proxy access to the records of their children. Reference Nebraska Medicine’s One Chart | Patient (Electronic Health Record Portal) policy, IM45, for current information on eligibility for patient and proxy access.

#*The information requested is not maintained by UNMC or ACE. If HIM knows where such information is maintained, the location should be noted in our response to the Individual;

#*The information requested is subject to the Privacy Act, 5 U.S.C. § 552(a);

#*The request is for access to [https://wiki.unmc.edu/index.php?title=Access_to_Designated_Record_Set&action=submit#Psychotherapy_Notes Psychotherapy notes];

#*The requested information was compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding;  

#*The request is for information regarding on-going research where treatment is being rendered as part of such research, provided that the Individual has agreed to the denial of access when consenting to participate in the research, and the health care provider providing treatment has informed the Individual that the right of access will be reinstated upon completion of the research;

#*The information was obtained from someone other than a health care provider under a promise of confidentiality, and the access requested would be reasonably likely to reveal the source of the information; or

#*The request is from an inmate of a correctional facility and treatment was provided to the inmate under the direction of the correctional facility. The correctional facility must notify HIM/UNMC that obtaining a copy would jeopardize the health, safety, security, custody or rehabilitation of the Individual. HIM may provide copies to the correctional facility to arrange for inspection by the inmate.

#*An attending physician 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;

#*The PHI makes reference to another person (unless such 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  

#*The request for access is made by the Individual's personal representative and a 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.

===Amendment of Designated Record===

Individuals have the right to request amendment of PHI about them which is maintained by UNMC or its business associates in the DRS. HIM/UNMC shall receive and process such requests according to the following procedures:

#*HIM will review the form for completion. If any information is incomplete, HIM will notify the Individual that UNMC cannot process the incomplete request. HIM will document on the Request form the attempts to contact the Individual.

#*HIM shall contact the author of clinical PHI to approve/deny the requested amendment. If the author is a medical student, resident or allied health professional with a supervising physician, the supervising physician shall approve/deny the requested amendment. If the request involves billing or payment information, Patient Financial Services should be consulted.

#Notifying Third Parties.   

#*UNMC will make reasonable attempts to notify those persons/entities who are identified by the patient of the amendment.

#*The disputed information is not subject to access by the Individual. (Refer to the section on Requests for Access above.)

#*The information is accurate and complete as written. '''Note:''' If the requested amendment relates to clinical information, HIM must consult with the licensed health care professional who created the information or an appropriate alternate if such person is not available to determine whether the information is accurate and complete.

#*Rights of Individual if the Request is Denied. UNMC must permit the Individual to submit a written statement of disagreement to UNMC. The statement of disagreement must be in writing and limited to one page.

#If a statement of disagreement is submitted, all future disclosures of the disputed information must include the following: Request for Amendment; Denial Notice; Statement of Disagreement; and UNMC’s Rebuttal (if any).

#If a statement of disagreement is not submitted, the Individual has the right to request that UNMC attach the Request for Amendment and Denial Notice to any future disclosures of the disputed information. Attach such Request only upon request of the Individual.

#Rebuttal by UNMC. UNMC will generally not issue a rebuttal statement unless special circumstances warrant. The author of the information should be consulted if HIM believes that a particular statement of disagreement submitted by a patient warrants a rebuttal by UNMC.  

==Additional Information==

*Contact [mailto:privacy@nebraskamed.com Privacy Officer]

*UNMC Policy No. 6045, [https://wiki.unmc.edu/index.php/Privacy/Confidentiality Privacy, Confidentiality and Security of Patient and Proprietary Information]

*UNMC Policy No. 6051, [https://wiki.unmc.edu/index.php/Computer_Use/Electronic_Information Computer Use/Electronic Information]

*Nebraska Medicine’s One Chart | Patient (Electronic Health Record Portal) policy, IM45

*[https://www.cdc.gov/phlp/publications/topic/hipaa.html Health Insurance Portability and Accountability Act of 1996 (HIPAA)]  

*[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]

*[Patient Access Request form]  

*[Authorization for Release of Information]