University of Nebraska Medical Center

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It is the policy of Nebraska Medicine/UNMC to comply with the procedures set forth below.<br />
It is the policy of Nebraska Medicine/UNMC to comply with the procedures set forth below.<br />


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.
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#*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. (See the [Extension Notice] provided with this policy.)
#*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. (See the [Extension Notice] provided with this policy.)
#'''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 patient’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.
#*If PHI is maintained electronically in one or more Designated Record Sets 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 Nebraska Medicine/UNMC. If Nebraska Medicine/UNMC and the individual cannot agree on an electronic form and format, then Nebraska Medicine/UNMC must provide a hard copy option to fulfill the access request.
#*If PHI is maintained electronically in one or more Designated Record Sets 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 Nebraska Medicine/UNMC. If Nebraska Medicine/UNMC and the Individual cannot agree on an electronic form and format, then Nebraska Medicine/UNMC must provide a hard copy option to fulfill the access request.
#*If the individual directs Nebraska Medicine/UNMC to transmit an electronic copy to a third party, Nebraska Medicine/UNMC will comply with such request, provided that the Individual's directions are clear, conspicuous and specific, and the direction is in writing. If the Individual's directions are not clear, conspicuous and specific, Nebraska Medicine/UNMC will attempt to contact the individual to clarify their request. Nebraska Medicine/UNMC may provide the Individual with a summary (abstract) of the PHI requested, ''in lieu'' of providing access to PHI or may provide an explanation of the PHI to which access has been provided, if the individual agrees to the summary or explanation in advance, including any fees imposed for such summary or explanation (see Fees below, in Section 7).
#*If the Individual directs Nebraska Medicine/UNMC to transmit an electronic copy to a third party, Nebraska Medicine/UNMC will comply with such request, provided that the Individual's directions are clear, conspicuous and specific, and the direction is in writing. If the Individual's directions are not clear, conspicuous and specific, Nebraska Medicine/UNMC will attempt to contact the individual to clarify their request. Nebraska Medicine/UNMC may provide the Individual with a summary (abstract) of the PHI requested, ''in lieu'' of providing access to PHI or may provide an explanation of the PHI to which access has been provided, if the Individual agrees to the summary or explanation in advance, including any fees imposed for such summary or explanation (see Fees below, in Section 7).
#'''Fees'''. If an Individual requests a copy of the PHI, Nebraska Medicine/UNMC may impose cost-based fees, not to exceed $0.50 (50 cents) per page. The basis for calculating such fee must be documented and may include staff time to create and copy the electronic file, such as compiling, extracting, scanning and writing the information to portable media. The cost-based fee may also include the cost of the agreed-upon electronic media, such as a USB drive, or creating a paper copy. If a summary or explanation is requested in advance by the Individual and the Individual has agreed to the fee for such request, Nebraska Medicine/UNMC may charge a pre-determined fee for preparation of such summary or explanation. Reference the fee schedule attached to Nebraska Medicine HIM department policy, Responding to Requests for Clinical Information: External Requestors, ROI 050.
#'''Fees'''. If an Individual requests a copy of the PHI, Nebraska Medicine/UNMC may impose cost-based fees, not to exceed $0.50 (50 cents) per page. The basis for calculating such fee must be documented and may include staff time to create and copy the electronic file, such as compiling, extracting, scanning and writing the information to portable media. The cost-based fee may also include the cost of the agreed-upon electronic media, such as a USB drive, or creating a paper copy. If a summary or explanation is requested in advance by the Individual and the Individual has agreed to the fee for such request, Nebraska Medicine/UNMC may charge a pre-determined fee for preparation of such summary or explanation. Reference the fee schedule attached to Nebraska Medicine HIM department policy, Responding to Requests for Clinical Information: External Requestors, ROI 050.
#'''Production of Records'''. If access to the requested information is granted in whole or in part, HIM will arrange for a convenient time and place for the patient to inspect the records or obtain a copy.
#'''Production of Records'''. If access to the requested information is granted in whole or in part, HIM will arrange for a convenient time and place for the Individual to inspect the records or obtain a copy.
#*Inspection will generally be during normal business hours of Nebraska Medicine/UNMC, unless special circumstances are present. Consult the [mailto:privacy@nebraskamed.com Privacy Officer] if the Individual requests to inspect the records or obtain a copy before or after normal business hours.
#*Inspection will generally be during normal business hours of Nebraska Medicine/UNMC, unless special circumstances are present. Consult the [mailto:privacy@nebraskamed.com Privacy Officer] if the Individual requests to inspect the records or obtain a copy before or after normal business hours.
#At the Individual’s request, HIM will mail a copy of the records in the format requested to the Individual at the address designated on the request form. If requested by the Individual, HIM will email a copy of the records to the Individual. ''If the Individual requests the records be sent by unsecured email, HIM will confirm that the Individual understands the information could be intercepted before complying with the request.''  
#At the Individual’s request, HIM will mail a copy of the records in the format requested to the Individual at the address designated on the request form. If requested by the Individual, HIM will email a copy of the records to the Individual. ''If the Individual requests the records be sent by unsecured email, HIM will confirm that the Individual understands the information could be intercepted before complying with the request.''  
#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. 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 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 his/her 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 form at Attachment 1) please advise name of form and where located (URL)'''. 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.
#'''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 form at Attachment 1) please advise name of form and where located (URL)'''. 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/UNMC or UNMC. If HIM knows where such information is maintained, the location should be noted in our response to the Individual;
#*The information requested is not maintained by Nebraska Medicine/UNMC or UNMC. If HIM knows where such information is maintained, the location should be noted in our response to the Individual;
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#'''Approval'''. If the amendment is accepted in whole or in part, HIM must identify the records containing the information. Such records will be amended by lining through the information and appending the amendment, or by providing a link to the location of the amendment. The original information should never be erased or removed from the record.   
#'''Approval'''. If the amendment is accepted in whole or in part, HIM must identify the records containing the information. Such records will be amended by lining through the information and appending the amendment, or by providing a link to the location of the amendment. The original information should never be erased or removed from the record.   
#'''Notifying Third Parties'''.   
#'''Notifying Third Parties'''.   
#*Nebraska Medicine/UNMC will make reasonable attempts to notify those persons/entities who are identified by the patient of the amendment.
#*Nebraska Medicine/UNMC will make reasonable attempts to notify those persons/entities who are identified by the Individual of the amendment.
#*Nebraska Medicine/UNMC will identify other persons/entities (including business associates of Nebraska Medicine/UNMC) that Nebraska Medicine/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. Nebraska Medicine/UNMC will obtain the patient’s permission to notify parties identified by Nebraska Medicine/UNMC as described above and will make reasonable attempts to notify those third parties of the amendment.
#*Nebraska Medicine/UNMC will identify other persons/entities (including business associates of Nebraska Medicine/UNMC) that Nebraska Medicine/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 Individual. Nebraska Medicine/UNMC will obtain the Individual’s permission to notify parties identified by Nebraska Medicine/UNMC as described above and will make reasonable attempts to notify those third parties of the amendment.
#'''Denial'''. Requests for amendment may be denied if one of the following grounds for denial exists:
#'''Denial'''. Requests for amendment may be denied if one of the following grounds for denial exists:
#*The information or record was not created by Nebraska Medicine/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 information or record was not created by Nebraska Medicine/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.
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#*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 Nebraska Medicine/UNMC’s Rebuttal (if any).
#*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 Nebraska Medicine/UNMC’s Rebuttal (if any).
#*If a statement of disagreement is not submitted, the Individual has the right to request that Nebraska Medicine/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.
#*If a statement of disagreement is not submitted, the Individual has the right to request that Nebraska Medicine/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 Nebraska Medicine/UNMC'''. Nebraska Medicine/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 Nebraska Medicine/UNMC.  
#'''Rebuttal by Nebraska Medicine/UNMC'''. Nebraska Medicine/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 an Individual warrants a rebuttal by Nebraska Medicine/UNMC.  
#'''Timeframe for Response'''. HIM shall respond back to the requestor in writing within 60 days of the date Nebraska Medicine/UNMC received the amendment request. If HIM determines that Nebraska Medicine/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.
#'''Timeframe for Response'''. HIM shall respond back to the requestor in writing within 60 days of the date Nebraska Medicine/UNMC received the amendment request. If HIM determines that Nebraska Medicine/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.
#'''Recordkeeping'''. The request for amendment, denial of the request, and statement of disagreement/rebuttal statement (if any) must be placed (append or otherwise linked in the electronic record) in the DRS and provided to the Individual as a part of a request for access.  
#'''Recordkeeping'''. The request for amendment, denial of the request, and statement of disagreement/rebuttal statement (if any) must be placed (append or otherwise linked in the electronic record) in the DRS and provided to the Individual as a part of a request for access.  
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