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Policy No.: '''6059'''<br /> | Policy No.: '''6059'''<br /> | ||
Effective Date: '''03/17/03'''<br /> | Effective Date: '''03/17/03'''<br /> | ||
Revised Date: ''' | Revised Date: '''10/28/22 Draft'''<br /> | ||
Reviewed Date:<br /> | Reviewed Date:<br /> | ||
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Nebraska Medicine/UNMC 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)]. | Nebraska Medicine/UNMC 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)]. | ||
==Purpose== | ==Purpose== | ||
To establish guidelines for individual access to and request for amendment of Protected Health Information (PHI) contained in the Designated Record Set. | To establish guidelines for individual access to and request for amendment of Protected Health Information (PHI) contained in the Designated Record Set (DRS). | ||
==Procedures== | ==Procedures== | ||
===Records Designated as Designated Records Set | ===Records Designated as Designated Records Set=== | ||
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. | |||
#'''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] 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] 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. | ||
#'''Review for Completeness'''. When a Patient Access Request or Authorization for Release of Information form is received, HIM shall review the form for completion. If any information is incomplete that is necessary for an access request ('''NOTE:''' some information on the Authorization for Release of Information is not necessary for a request for access), HIM will notify the Individual that they cannot process the incomplete request. HIM should document on the form the attempts to contact the Individual. | #'''Review for Completeness'''. When a Patient Access Request or Authorization for Release of Information form is received, HIM shall review the form for completion. If any information is incomplete that is necessary for an access request ('''NOTE:''' some information on the Authorization for Release of Information is not necessary for a request for access), HIM will notify the Individual that they cannot process the incomplete request. HIM should document on the form the attempts to contact the Individual. | ||
#'''Timeframe for Response.''' | #'''Timeframe for Response.''' | ||
#*If examination of the records is requested, Nebraska Medicine/UNMC shall make the records available for inspection within ten (10) days of the date Nebraska Medicine/UNMC received the request. | #*If examination of the records is requested, Nebraska Medicine/UNMC shall make the records available for inspection within ten (10) days of the date Nebraska Medicine/UNMC received the request. | ||
#*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 Nebraska Medicine/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. | #*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 Nebraska Medicine/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. | ||
#'''If copies of the records are requested, Nebraska Medicine/UNMC must produce the requested copies within 30 days of the date Nebraska Medicine/UNMC received the request. No extension of this date is permitted without the Individual’s consent.''' | #'''If copies of the records are requested, Nebraska Medicine/UNMC must produce the requested copies within 30 days of the date Nebraska Medicine/UNMC received the request. No extension of this date is permitted without the Individual’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, Nebraska Medicine/UNMC must provide such information to the Individual in the form and format requested by the Individual, if it is readily producible. If Nebraska Medicine/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. | #*If PHI is maintained electronically in one or more DRS for such Individual and the Individual requests an electronic copy of their information, Nebraska Medicine/UNMC must provide such information to the Individual in the form and format requested by the Individual, if it is readily producible. If Nebraska Medicine/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. | ||
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#If the Individual 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 Individual. | #If the Individual 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 Individual. | ||
#The Individual 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. Individuals 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 Individuals to view portions of their medical and billing record. Individuals 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 Individual 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. Individuals 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 Individuals to view portions of their medical and billing record. Individuals 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 Individual must be provided with a written denial, including the basis for denial; a statement of their review rights under n below if applicable; and a description of how the Individual may file a complaint to Nebraska Medicine/UNMC, along with name, title, and telephone number, or to the Secretary Health and Human Services '''(see | #'''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 Individual must be provided with a written denial, including the basis for denial; a statement of their review rights under n below if applicable; and a description of how the Individual may file a complaint to Nebraska Medicine/UNMC, along with name, title, and telephone number, or to the Secretary Health and Human Services '''(see [ Denial of Access to Medical Record/Billing Record]) . If Nebraska Medicine/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, Nebraska Medicine/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 their DRS for reasons listed below without providing the Individual with an opportunity for review. | #'''Unreviewable Grounds for Denial of Access'''. HIM, in coordination with the Privacy Office, may deny the Individual the right to access their DRS for reasons listed below without providing the Individual with an opportunity for review. | ||
#*The information requested is not maintained by Nebraska Medicine/ | #*The information requested is not maintained by Nebraska Medicine/UNMC. 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 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 | #*The request is for access to [https://wiki.unmc.edu/index.php/Access_to_Designated_Record_Set#Psychotherapy_Notes Psychotherapy notes] (also see UNMC Policy No. 6066, [[Psychotherapy Notes]]); | ||
#*The requested information was compiled in reasonable anticipation of, or for use in, a civil, criminal or administrative action or proceeding; | #*The requested information was compiled in reasonable anticipation of, or for use in, a civil, criminal or administrative action or proceeding; | ||
#*The information requested is maintained by a clinical laboratory subject to the [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], and access by the Individual is prohibited by law; | #*The information requested is maintained by a clinical laboratory subject to the [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], and access by the Individual is prohibited by law; | ||
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==Definitions== | ==Definitions== | ||
===Affiliated Covered Entity (ACE)=== | ===Affiliated Covered Entity (ACE)=== | ||
Legally separate covered entities that designate themselves as a single covered entity for the purpose of HIPAA Compliance. Current ACE members are: The Nebraska Medical Center, UNMC Physicians, UNMC, University Dental Associates, Bellevue Medical Center and Nebraska Pediatric Practice, Inc. d/b/a Children’s Specialty Physicians. ACE membership may change from time to time. The Notice of Privacy Practices lists current ACE members. | Legally separate covered entities that designate themselves as a single covered entity for the purpose of HIPAA Compliance. Current ACE members are: The Nebraska Medical Center, UNMC Physicians, UNMC, University Dental Associates, Bellevue Medical Center and Nebraska Pediatric Practice, Inc. d/b/a Children’s Specialty Physicians. ACE membership may change from time to time. The Notice of Privacy Practices lists current ACE members. | ||
===Designated Record Set (DRS)=== | ===Designated Record Set (DRS)=== | ||
Includes medical records and billing records about Individuals maintained by or for UNMC/ACE and any other record used by | Includes medical records and billing records about Individuals maintained by or for UNMC/ACE and any other record used by the ACE to make decisions about Individuals. | ||
===Individual=== | ===Individual=== | ||
The person who is the subject of the PHI. Personal representatives of the Individual have the same rights as the Individual under HIPAA (i.e., they “step into the shoes” of the Individual). Personal representatives include the legal guardian and anyone else authorized by law to act on behalf of the Individual. (See Nebraska Medicine Consents and Permits policy, MS14.) | The person who is the subject of the PHI. Personal representatives of the Individual have the same rights as the Individual under HIPAA (i.e., they “step into the shoes” of the Individual). Personal representatives include the legal guardian and anyone else authorized by law to act on behalf of the Individual. (See Nebraska Medicine Consents and Permits policy, MS14.) | ||
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*an Individual’s genetic tests; | *an Individual’s genetic tests; | ||
*the genetic tests of an Individual’s family members; or | *the genetic tests of an Individual’s family members; or | ||
*the manifestation of a disease or disorder in such Individual’s family members (i.e., family medical history) | *the manifestation of a disease or disorder in such Individual’s family members (i.e., family medical history). | ||
PHI excludes: | PHI excludes: | ||
*individually identifiable health information of a person who has been deceased for more than fifty (50) years. | *individually identifiable health information of a person who has been deceased for more than fifty (50) years. | ||
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*employment records held by UNMC in its role as employer. | *employment records held by UNMC in its role as employer. | ||
===Psychotherapy Notes=== | ===Psychotherapy Notes=== | ||
Notes recorded (in any medium) by a | Notes recorded (in any medium) by a mental health provider including psychiatrists, psychologists and other mental health professionals documenting or analyzing the contents of a conversation during a private counseling session or group, joint or family counseling session. Psychotherapy notes are kept separate from the rest of the individual’s medical record. Psychotherapy notes exclude 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. Psychotherapy notes are not progress notes and are created at the discretion of the mental health care provider. (HIPAA: 45 CFR §164.501) | ||
==Additional Information== | ==Additional Information== | ||
*Contact [mailto:privacy@nebraskamed.com Privacy Officer] | *Contact [mailto:privacy@nebraskamed.com Privacy Officer] | ||
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*UNMC Policy No. 6051, [https://wiki.unmc.edu/index.php/Computer_Use/Electronic_Information Computer Use/Electronic Information] | *UNMC Policy No. 6051, [https://wiki.unmc.edu/index.php/Computer_Use/Electronic_Information Computer Use/Electronic Information] | ||
*UNMC Policy No. 6057, [https://wiki.unmc.edu/index.php/Use_and_Disclosure_of_Protected_Health_Information Use and Disclosure of Protected Health Information] | *UNMC Policy No. 6057, [https://wiki.unmc.edu/index.php/Use_and_Disclosure_of_Protected_Health_Information Use and Disclosure of Protected Health Information] | ||
*UNMC Policy No. 6066, [[Psychotherapy Notes]] | |||
*Procedure for UNMC Policies No. 6051 and 6057, [https://info.unmc.edu/its-security/policies/procedures/electronic-comm-phi.html Electronic Communication of Protected Health Information] | *Procedure for UNMC Policies No. 6051 and 6057, [https://info.unmc.edu/its-security/policies/procedures/electronic-comm-phi.html Electronic Communication of Protected Health Information] | ||
*Nebraska Medicine Consents and Permits policy, MS14. | *Nebraska Medicine Consents and Permits policy, MS14. | ||
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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] | ||
*[Patient Access Request form] | *[ CMS-1500 form] '''( form name and URL please)''' | ||
*[Authorization for Release of Information] | *[ Health Care Financing Administration claim form (HCFA)] '''(URL please)''' | ||
*[ | *[Patient Access Request form] (not yet approved) | ||
*[ | *[Authorization for Release of Information Form, CON MR 0074] | ||
*Notice of Approved/Denied Request for Amendment form | *[ 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 | |||
*[ 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]. | ||