What do you need? Copy of the HIPAA Policy on Amendment of Protected Health Information

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1 HIPAA Privacy Prcedure #4 Effective Date: April 14, 2003 Reviewed Date: February, 2011 Amendment f Prtected Health Revised Date: February, 2011 Infrmatin Scpe: Radiatin Onclgy ************************************************************************************ Plicy Expectatin: Washingtn University (WU) has adpted a plicy t accmmdate the right f an Individual t request an Amendment f Prtected Health Infrmatin (PHI) created, received r held n behalf f the Individual. Infrmatin nt cntained within a Designated Recrd Set is nt subject t this Plicy: including infrmatin cmpiled in reasnable anticipatin f civil, criminal, r administrative actin r ther prceeding; and prhibited r exempt frm Disclsure under that Act. Individuals d nt have the right t request an Amendment f PHI if Radiatin Onclgy did nt create the PHI, unless the Individual prvides reasnable basis t believe that the riginatr f the PHI is n lnger available. Why is this imprtant? Cmpliance with all HIPAA privacy regulatins is required f all Radiatin Onclgy Divisins creating r cllecting PHI frm r n behalf f Individuals. Failure t cmply may result in being liable fr civil and criminal penalties under the HIPAA regulatins. What d yu need? Cpy f the HIPAA Plicy n Amendment f Prtected Health Infrmatin IMPORTANT NOTE ON HOW TO USE THIS PROCEDURE: A change in demgraphic infrmatin (i.e., name, address, religin) and insurance infrmatin (i.e., plan, ID number) is an accunt update and NOT an amendment under HIPAA. Therefre, a Request t Amend is nt necessary. Radiatin Onclgy patient medical recrds are wned by Barnes-Jewish Hspital. Requests fr amendment in the patient medical recrd shuld be directed t BJH HIPAA cntact. Requests fr amendment f billing recrds (i.e., diagnsis n an insurance claim) shuld be directed t bth BJH HIPAA cntact and WU-RO Privacy Liaisn.

2 Steps: 1. Guide the inquiring Individual in cmpletin f a Written Request t Amend PHI. Make sure that the cmpleted frm includes the reasn fr the request. Make the frm available in hard cpy r by electrnic means. Additinal Infrmatin Mst requests fr amendment will likely ccur at the lcal level (ne item in ne medical recrd). If the University Privacy Office is the first recipient f the request, the request will be frwarded t Radiatin Onclgy Privacy Liaisn. See Exhibit A, Request fr Amendment f Prtected Health Infrmatin. This frm can be kept n yur cmputer and ed as an attachment t individuals. If the reasn fr the request is nt stated the request may be denied. 2. Frward the request t the Radiatin Onclgy Privacy Liaisn RO Privacy Liaisn Kevin Sharkey ksharkey@radnc.wustl.edu Tel: Fax: Campus Bx The RO Privacy Liaisn, after reviewing the request and determining the necessity fr review, will then cntact the prvider and ntify them f the request and the time perid the respnse is required within (within 60 days frm date request was received.) 4.The RO Privacy Liaisn will cmmunicate with the patient if there is a need t extend the respnse time t the Individual past the 60 day perid. State in the request fr extensin the reasn fr the delay. Only ne 30 day extensin is allwed. See Appendix B Request fr Extensin f Time t Respnd t Amendment.

3 5. Granting the Request fr Amendment: The RO Privacy Liaisn will: Identify the dcuments/data in the Designated Recrd Set that are subject t the request fr amendment Determine the prtin(s) f the Designated Recrd Set t which the amendment request pertains. Clearly mark each area fr review by the prvider If the request is accepted, the RO Privacy Liaisn will ntify the individual requesting. Cnfirm with the requesting Individual the names f persns wh may have received this PHI and will need the amendment. Check department resurces t determine t whm the Original PHI was sent and will nw need amended PHI. Obtain the requesting Individuals agreement t permit RO t ntify the RO Business Assciates and thers t share the amendment with them. Make reasnable effrts t infrm and prvide the amended PHI t all parties authrized by the requesting Individual. D nt remve recrds. Keep entire chart intact. D nt change recrds. Identify the Business Assciates and thers that WU knws have PHI subject t the amendment. 6. RO Privacy Liaisn will send t BJH Medical Recrds Staff r apprpriate PHI Recrd custdian the cmpleted request frm with reslutin fr filing.

4 7. Denying the Request t Amend PHI: Prvide a written ntice f denial within 60 days (unless extensin has been btained) f the written request. A cpy f this denial letter shuld be sent t the BJH medical recrd custdian t secure t the same page as the infrmatin the patient was requesting amended. A cpy f the Denial letter must be frwarded t the University Privacy Office. See Exhibit A Request frm fr the sectin t be cmpleted in denials. See example f denial letter. The ntice f denial must include infrmatin n: the individual s right t submit a written Statement f Disagreement with the denial an explanatin f hw the individual may file the Statement f Disagreement the right f the individual t have the request fr amendment included with any future disclsures f PHI, if n Statement f Disagreement is filed. a descriptin f the cmplaint prcess t be fllwed fr cmplaint related t privacy cncerns in this matter Statements f Disagreement must be accepted but may be limited t 2 pages. 8. Recrd keeping f Denials Identify the PHI in the Designated Recrd Set that is the subject f the requested amendment and append r therwise link: the individual s request fr amendment RO s denial f the request fr amendment the individual s Statement f Disagreement (if ne is submitted) the respnse t the Statement f Disagreement (if ne is prepared) 9. A cpy will be sent by WU-RO Privacy Liaisn t the RO Medical Recrds Custdian t place dcumentatin in the medical recrd.

5 10. If the patient submits a Statement f Disagreement, this must be: a. Sent t the medical recrd custdian t secure t the Request fr Amendment and Denial Letter. b. Frwarded t the RO Privacy Liaisn This Statement f Disagreement must be included in all releases f the medical recrds t which the Statement applies. c. It is recmmended that it be flagged n the chart in the fllwing manner by the Medical Recrd Custdian. In red marker n the frnt f the chart a ntatin STATEMENT OF DISAGREEMENT 11. Respnse Statements - If the RO Privacy Liaisn r prvider feels that there shuld be a written respnse t any Statement f Disagreement submitted by an Individual: a. RO Privacy Liaisn will prvide a cpy f this t the Individual and send a cpy t RO Medical Recrds t be placed in the chart and secured t the same page as the Request fr Amendment, Denial and Statement f Disagreement. b. Recmmend the chart be flagged by the Medical Recrd Custdian in red marker, n the frnt REBUTTAL STATEMENT The recrd shuld be flagged t alert staff t send the Statement f Disagreement with any PHI pertaining t the denied Amendment request. 12. This Rebuttal Statement, alng with the Statement f Disagreement, must als be included in any disclsures f PHI t which the Statement f Disagreement applies. 13. Fr transactins invlving billing, WU-Physician Billing representative will separately transmit Statements f Disagreement r the riginal request and denial fr physician health care claims. WU-Physician Billing Campus Bx 8239

6 14. If a ntice f amendment is received frm anther cvered entity, amend the individuals PHI in the Designated Recrd Set held by RO. RO Chief f Service t review and make the amendment. A cpy must be frwarded t the RO Medical Recrds t file the amendment in Patient s Medical Recrd. The RO HIPAA Privacy Liaisn will recrd receipt f amendment in lg with date received. 15. Future Disclsures f Denied PHI Amendment If a Statement f Disagreement is submitted by the individual, include Statement and Denial Letter, in any future disclsures f the PHI t which the disagreement relates. Must include either the riginal Statement f Disagreement r an accurate summary f the denial circumstances. The recrd shuld be flagged by RO Medical Recrds t alert staff t send the Statement f Disagreement with any PHI pertaining t the denied amendment request. 16. If a Statement f Disagreement is nt submitted, the individual must make knwn in writing his/her wishes related t the Request fr PHI Amendment and the denial being included in any future disclsure f the disputed PHI. If n such request is made the infrmatin, des nt have t be included in future disclsures. 17. Each request will be lgged, mnitred fr timely review, prcessing steps and final reslutin by the RO Privacy Liaisn.

7 Exhibit A Request fr Amendment f Prtected Health Infrmatin Request Date: Individual Name: Date f Birth: SSN: Patient Address: Telephne Number: (H) (W) Medical Recrd # : After review f my medical recrd, I am requesting that infrmatin n the fllwing service date(s) be amended/supplemented with clarifying infrmatin and added in the frm f an addendum t my medical recrd. I am requesting this amendment because: I understand that Washingtn University may r may nt amend/supplement my medical recrd based n my request. Under n circumstances, may Washingtn University alter the riginal dcumentatin f my medical recrd. Amendment Request: I request the fllwing amendment/supplement be made t my medical recrd: I hereby agree and acknwledge that Washingtn University will ntify thse persns I have designated belw as well as thers with whm Washingtn University has previusly shared my health infrmatin f this amendment f my health infrmatin. Signature (Individual r Legal Representative) Date D yu knw f anyne wh may have received r relied n the infrmatin in questin (such as yur dctr, pharmacist, health plan, r ther health care prvider)?

8 Yes N If yes, please specify the name(s) and address(es) f the rganizatin(s) r individual(s): Fr Washingtn University Use Only: Amendment has been: Accepted Denied In respnse t yur request, an amendment/supplement will be made part f yur permanent medical recrd. Yur request has been denied fr the fllwing reasns: Infrmatin was nt created by this rganizatin. Infrmatin is nt part f the Designated Recrd Set. Federal law prhibits making the Infrmatin available t the patient fr inspectin (e.g. psychtherapy ntes). Infrmatin is accurate and cmplete. Other: Staff cmments: Signature f Staff Persn Date Print Name & Title Statement f Disagreement:

9 If yu d nt agree with the abve infrmatin, yu may submit a Statement f Disagreement that will becme part f yur permanent recrd and included in any future disclsure f the subject medical infrmatin. Please utline the reasn fr yur disagreement in the space prvided belw: (may attach n mre than 2 pages) I d nt wish t submit a Statement f Disagreement. Hwever, I am requesting that Washingtn University include in any future disclsure my request fr amendment frm and Washingtn University s denial. Individual r Legal Representative Signature Date Frward r mail, pstage pre-paid, this frm t: Washingtn University ATTN:

10 Exhibit B Request fr Extensin f Time t Respnd t Amendment T [Individual]: We have received yur Request fr Amendment f Prtected Health Infrmatin maintained by Washingtn University and are in the prcess f respnding t yur request. Federal regulatins require us t respnd t yur request within 60 days f ur receipt f the request. If we are unable t respnd within such time, we may receive a ne-time extensin f 30 days within which we will prvide yu with a respnse t yur requested amendment. Currently, we are experiencing delays in ur prcessing f the review f yur request due t [INSERT REASON FOR DELAY] and will require an additinal 30 days t respnd t yur request. We appreciate yur patience in this matter and will prvide yu with a respnse t yur requested amendment by [Date that is nt greater than 90 days frm the receipt date]. If yu have questins cncerning yur request, please cntact [INSERT NAME OR TITLE OF PERSON] at Washingtn University [INSERT CONTACT INFORMATION]. Sincerely,