Access to Designated Record Set: Difference between revisions

Revised Date: '''08/19/22 Draft'''<br />

Nebraska Medicine/UNMC ("Organization"), shall provide individuals access to inspect and obtain a copy of Protected Health Information (PHI) contained in the Designated Record Set (DRS) maintained by Nebraska Medicine/UNMC or its business associates, and to request amendment to such information, in accordance with the [https://www.cdc.gov/phlp/publications/topic/hipaa.html Health Insurance Portability and Accountability Act of 1996 (HIPAA)].   

#*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.

#'''Denials of Access'''. HIM should review the request to determine if one or more of the following grounds for denying access exists as to all or part of the requested records. Access may be denied, in coordination with HIM and the Privacy Office, for reasons listed under Sections 13 and 14 below. The patient must be provided with a written denial, including the basis for denial; a statement of their review rights under section 14 below if applicable; and a description of how the Individual may file a complaint to HIM/UNMC, along with name, title and telephone number, or to the Secretary Health and Human Services (see form at Attachment 1). If UNMC does not maintain the PHI that is the subject of the Individual's request for access, and knows where the requested information is maintained, UNMC will inform the Individual where to direct the request for access.

#'''Unreviewable Grounds for Denial of Access'''. HIM, in coordination with the Privacy Office, may deny the Individual the right to access his/her DRS for reasons listed below without providing the Individual with an opportunity for review.  

#*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 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.

#'''Review of Denial'''. Upon request, the Individual has the right to have denials listed under section 14 above reviewed by another licensed health care professional who did not participate in the original denial. The Nebraska Medicine Chief Medical Officer is the designated reviewing official. If the Chief Medical Officer is not available, the Nebraska Medicine Clinical Governance Committee chair shall review the request. Requests shall be reviewed as soon as possible, but no later than thirty (30) days from submission of the request. HIM must promptly provide written notice to the Individual of the determination of the designated reviewing official, which is final. If access to any information is denied, HIM/UNMC will, to the extent possible, provide access to any remaining information after the information to which access was denied has been removed or redacted.

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:

#Individuals may submit a written Request for [Correction/Amendment of Medical/Billing Information form] to HIM, providing rationale for the requested amendment.   

#*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.

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

#*HIM and UNMC will identify other persons/entities (including business associates of UNMC) that HIM/UNMC knows to be in possession of the information and who may have relied on the information or could foreseeably rely on the information to the detriment of the patient. HIM/UNMC will obtain the patient’s permission to notify parties identified by HIM/UNMC as described above and will make reasonable attempts to notify those third parties of the amendment.

#*The information or record was not created by UNMC. '''Note:''' Continue to process the request if the Individual provides credible information that the creator of the information or record is not available to act on a request for 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.

#'''Notifying the Individual of the Denial'''. If one of the above grounds exists, HIM will notify the Individual that UNMC has denied the request for amendment, using the Notice of Approved/Denied Request for Amendment form. The notice should inform the Individual of their rights regarding the denied request for amendment.

#'''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.  

#'''Timeframe for Response'''. HIM shall respond back to the requestor in writing within 60 days of the date UNMC received the amendment request. If HIM determines that UNMC is unable to respond to the request within sixty (60) days, HIM must notify the Individual in writing that one 30-day extension is necessary to respond to the request and shall provide the reasons the extension is necessary. The extension notice must state the date by which action on the request will be taken.