Statement of Policy
Washington University and its member organizations (collectively, “Washington University” or “WU”) are committed to conducting business in compliance with all applicable laws, regulations, and WU policies. As part of this commitment, WU has adopted a policy to facilitate the proper review and evaluation of Individual requests to amend Protected Health Information (PHI).
Scope of Policy
Individuals have the right to request an Amendment of their PHI within a Designated Record Set, defined herein. Information not contained within a Designated Record Set is not subject to this Policy. Additional exclusions from this Policy include PHI not available for access by Individuals such as: psychotherapy notes; information compiled in reasonable anticipation of civil, criminal, or administrative action or other proceeding; and PHI maintained for compliance with Clinical Laboratory Improvements Amendments (“CLIA”) and prohibited or exempt from Disclosure under that Act.
1) Processing Requests for Amendment
a) Documents Subject to Amendment. An Individual may request an Amendment of his or her PHI maintained in a Designated Record Set. A Designated Record Set should include:
i) Face Sheet (Admission Information, Registration, Insurance)
ii) Physician Orders
iii) Vital Sign Work Sheet
iv) Intake and Output Records
v) Admission, Progress and Discharge Notes
vi) History and Physical
vii) Nurses Notes and Other Ancillary Provider Notes
viii) Radiology Reports
ix) Pathology, Laboratory and other Ancillary Reports
x) Operative Reports
xi) Discharge Summary
xii) Consultation Reports or Notes
xiii) Treatment Record such as problem lists, medication lists, plan of care
xiv) Patient Name, Address
xv) Plan (Insurer) Name, Patient ID Number
xvi) Provider Name, Address, Tax ID
xvii) Ordering/Referring Physician Name
xviii) Charge, Allowable, Paid by Plan, Paid by Patient, Paid by Other Source
xix) Contract Amount/Write Off/Disallowed/Denied Amount
xx) Diagnosis Codes
xxi) Procedure Codes and Modifiers
xxii) Units of Service
xxiii) Dates of Service
b) Where there is No Right of Amendment. Individuals do not have a right to amend PHI where the Amendment seeks to amend a record that:
i) is not a part of the Designated Record Set;
ii) is unavailable for access under the WU HIPAA Policy on Access by Individuals to Protected Health Information, such as Psychotherapy Notes; information compiled in reasonable anticipation of civil, criminal, or administrative action or other proceeding; and PHI maintained for compliance with CLIA and is prohibited from access or is exempt from Disclosure under the CLIA Act; or
iii) is believed by WU to be accurate and complete.
c) Persons Responsible for Handling Requests. WU will document the Designated Record Sets that are subject to Amendment and the titles of persons within the Business Units or member organizations (or designated correspondence clerk) responsible for receiving and processing requests for Amendment by Individuals.
d) Persons who should Decide to Grant or Deny an Amendment Request. WU will designate a licensed health care professional who will review requests for amendment of PHI. Such licensed health care professional may consult the author of the subject PHI prior to making a determination of the request for Amendment and whether a Designated Record Set is accurate and complete.
e) Request for Amendments. WU will inform Individuals that requests for Amendments to PHI must be submitted in writing on the form attached as Exhibit A and contain a reason to support a requested Amendment. Unless a reason to support the requested Amendment is stated, the request may be denied.
f) Response Timeframes and Extension.
i) WU will review and act upon requests for Individual Amendments to PHI no later than 60 days after receipt of such written request either by granting the request in accordance with Section 2 of this policy; by denying the request in accordance with Section 3 of this policy; or obtaining an extension within which to respond following the guidelines set forth in item (ii) below.
ii) WU may request and obtain a one-time extension of no more than 30 days within which it must take action on a request for Amendment.
• To obtain a one-time extension, WU will contact the requesting Individual, in writing and within the initial 60-day period, stating the reasons for the delay in its response and the date by which WU will complete its action on the request. (See Form, Exhibit B)
2) Grant of Amendment
a) Granting an Amendment. After a review of a request for Amendment, if WU grants a requested Amendment, either in whole or in part, it will:
i) identify the records in the Designated Record Set that are affected by the Amendment and append or otherwise link to the location of the Amendment. Do not remove the record from the Designated Records Set. The date and signature of the person implementing the Amendment should be noted;
ii) notify the Individual of the acceptance of the Amendment. (No explanation is necessary);
iii) confirm with the requesting Individual the identification of persons who have received the PHI and need the Amendment;
iv) identify the WU Business Associates and others that WU knows have the PHI subject to the Amendment and who may have relied or could rely on such information to the detriment of the Individual;
v) obtain the requesting Individual’s agreement to permit WU to notify the persons identified in (iii) and (iv) above and to share the Amendment with those parties; and
vi) take reasonable efforts to inform and provide, within a reasonable time, the Amendment to the people authorized in (v) above.
3) Denial of Amendment
a) Reasons for Denial. WU will deny requests for Amendment if it determines that the requesting Individual is attempting to amend PHI that:
i) was not created by WU, unless the requesting Individual provides a reasonable basis to believe that the originator of the PHI is no longer available;
ii) is not a part of the Designated Record Set;
iii) is not available for access as defined in the WU HIPAA Policy on Access by Individuals to Protected Health Information such as psychotherapy notes; information compiled in reasonable anticipation of civil, criminal, or administrative action or other proceeding; and PHI maintained for compliance with CLIA and is prohibited from access or is exempt from Disclosure under the CLIA Act; or
iv) is believed by WU to be accurate and complete.
b) Providing a Notice of the Denial Regardless of the ground(s) for denial, WU will provide a written notice of denial within 60 days of a request (unless an extension has been obtained) to the requesting Individual that states, in plain language: (See Exhibit A)
i) the authorized basis for the denial (See Section (3),(a) above);
ii) the Individual’s right to submit a written statement disagreeing with the denial and the basis of such disagreement (“Statement of Disagreement”) including an explanation of how the Individual may file his or her Statement of Disagreement (See Section (3),(c) below) with WU;
iii) the Individual’s right , if no Statement of Disagreement is filed, to request that WU include his or her request for Amendment and the denial of such Amendment with any future disclosures of the PHI that is subject of the requested Amendment; and
iv) a description of the complaint process that he or she may follow with the WU, including the name or title and telephone number of the contact person at the WU Business Unit or member organization responsible for receiving complaints of privacy concerns, or with the Secretary. See WU HIPAA Policy on Notice of Privacy Practices for the complaint process.
c) Statements of Disagreement.
i) WU will accept any Statement of Disagreement submitted by an Individual.
ii) WU may reasonably limit the length of Statement of Disagreement submitted by Individuals submitted to 2 pages.
d) Rebuttal Statements.
i) WU may prepare a written rebuttal statement to any Individual’s Statement of Disagreement submitted.
ii) If prepared, WU will provide a copy of such rebuttal to the Individual who submitted the Statement of Disagreement.
e) Recordkeeping of Denials. WU will identify the PHI in the Designated Record Set that is the subject of the disputed Amendment and append or otherwise link:
(i) The Individual’s request for an Amendment;
(ii) WU’s denial of the request for Amendment;
(iii) The Individual’s Statement of Disagreement (if any) submitted to WU, and
(iv) WU’s rebuttal to the Statement of Disagreement (collectively “Denial Materials”) to such PHI.
f) Future Disclosures of Denied Request to Amend PHI
i) If a Statement of Disagreement has been submitted by the Individual, WU must include in any future Disclosures either the Denial Materials described in Section (3), (e) above, or, at the election of the WU, an accurate summary of the Denial Materials with any future Disclosure of the PHI to which the disagreement relates.
ii) If no Statement of Disagreement is submitted by an Individual, the Individual must request that WU include in any future Disclosures either the Individual’s request for Amendment and its denial, or an accurate summary of such information. If no request is made, such material need not be included in any Disclosure.
iii) For transactions involving the standard Transaction code sets for billing, WU will separately transmit Statements of Disagreements or the original request and denial of an Individual if such materials may not be included as part of a Disclosure using the standard Transaction.
4) Amendment by Another Covered Entity
WU, including its Business Associates, will amend an Individual’s PHI upon receipt of notice of Amendment from another Covered Entity.
Creation Date: November 22, 2002
Effective Date: April 14, 2003
Last Revision Date: June 23, 2010