Purpose: The purpose of this policy is to ensure a patient’s rights related to the uses and/or disclosure of their protected health information (PHI) and to demonstrate compliance with the HIPAA privacy requirements.
Policy & Procedure
I. Inspect and Copy – A patient has a right of access to inspect and obtain a copy of PHI contained in their “designated record set,” for as long as the PHI is maintained, with some exceptions listed below.
A. The WYOMING COUNTY HEALTH DEPARTMENT may deny a patient’s access without providing an opportunity for review, in the following situations:
- psychotherapy notes;
- information compiled in reasonable anticipation of, or for use in, ca civil, criminal or administrative action or proceeding;
- PHI subject to Clinical Laboratory Improvements Amendments or 1988 (as applicable);
- information created or obtained through research that includes treatment may be temporarily suspended for as long as the research is in progress;
- for records subject to the Privacy Act 5 USC 552(a) access may be denied, if the denial would meet the requirements of that Act; and
- if the PHI was obtained from someone other than the WYOMING COUNTY HEALTH DEPARTMENT under a promise of confidentiality and the access of this information would reveal the source (who is not a healthcare provider).
B. The WYOMING COUNTY HEALTH DEPARTMENT may deny a patient access, provided that the patient is given a right to have such denials reviewed (as required by paragraph (a)(3) of 164.524) in the following situations:
- determination made in the exercise of professional judgment, by a licensed healthcare provider, t hat the access requested is likely to endanger the life or physical safety of the patient or another person;
- the PHI makes reference to another person (excluding a healthcare professional) and a determination is made in the exercise of professional judgment, by a licensed healthcare provider, that the access requested is likely to cause substantial harm to such other person;
- the request for access is made by the patient’s legal representative and a licensed healthcare professional has determined, in the exercise of professional judgment, that the provision of access to such legal representative is reasonably likely to cause substantial harm to the patient or another person.
C. In the case of a denial by the WYOMING COUNTY HEALTH DEPARTMENT, the patient has the right to have the denial reviewed by a licensed healthcare professional who is designated by the WYOMING COUNTY HEALTH DEPARTMENT as the reviewing official, who did not participate in the original decision. The WYOMING COUNTY HEALTH DEPARTMENT will abide by the decision of the reviewer.
D. If the denial stands, the WYOMING COUNTY HEALTH DEPARTMENT will comply with the rules as follows:
- make other information available;
- provide a timely written denial in clear language that must contain:
- the basis for the denial;
- a statement of the reviewer’s findings; and
- a description of the complaint process, for both the WYOMING COUNTY HEALTH DEPARTMENT and the Secretary of the Department of the Health and Human Services (DHHS), to include name, title, telephone and other contact information.
E. The WYOMING COUNTY HEALTH DEPARTMENT will act on a request for access within 30 days, if possible and may extend the time frame once not to exceed an additional 30 days.
F. The WYOMING COUNTY HEALTH DEPARTMENT may charge a reasonable fee for the access process. The fee will be based on the actual cost (such as the cost of supplies, the costs of labor for copying, postage, etc). This will not include a search and retrieval fee.
G. The WYOMING COUNTY HEALTH DEPARTMENT will retain the following documentation:
- the “designated record set” that is applicable;
- the title of the persons responsible for receiving and processing requests for access; and
- a log of requests that are processed.
H. If the WYOMING COUNTY HEALTH DEPARTMENT does not maintain the PHI that is the subject of the request and the WYOMING COUNTY HEALTH DEPARTMENT knows where the requested information is, it will inform the patient where to send the request.
II. Request Restriction of Uses and/or Disclosures – Patients have the right to request restriction of uses and/or disclosures of PHI for treatment, payment or other healthcare operations.
A. The WYOMING COUNTY HEALTH DEPARTMENT is not required to agree to a restriction. If the WYOMING COUNTY HEALTH DEPARTMENT agrees to a restriction, it will document the restriction and (as will our business associates) will honor the restriction, except in situations when the patient who requested the restriction is in need of emergency treatment and the restricted PHI is needed to provide the treatment.
B. The WYOMING COUNTY HEALTH DEPARTMENT may terminate its agreement to a restriction. Either the WYOMING COUNTY HEALTH DEPARTMENT may terminate its agreement to a restriction. Either the WYOMING COUNTY HEALTH DEPARTMENT or the patient can initiate the termination and it applies to the PHI created or received after the patient has been informed of the termination.
C. The WYOMING COUNTY HEALTH DEPARTMENT will make each patient aware of their right to request a restriction as part of giving him/her their initial Notice of Privacy Practices.
D. After reviewing a requested restriction with the patient, the WYOMING COUNTY HEALTH DEPARTMENT will document its decision. The WYOMING COUNTY HEALTH DEPARTMENT will discuss with the patient the potential need to use PHI in emergency situations and will attempt to manage specific accommodations. The decision made by the WYOMING COUNTY HEALTH DEPARTMENT will be communicated to the patient in a consistent and unbiased fashion.
E. If the WYOMING COUNTY HEALTH DEPARTMENT agrees to a restriction, it will be documented specifying the type of information to be included in the restriction, t o whom the restriction will apply and will retain this information for six (6) years from the date it was created or t he date it was last in effect, whichever is later.
F. The WYOMING COUNTY HEALTH DEPARTMENT will develop a process for complying with the restriction to which it as agreed and will inform others as appropriate of the restriction.
G. The WYOMING COUNTY HEALTH DEPARTMENT will develop a procedure for terminating a restriction. This procedure will include:
- the patient agreeing to (or requesting) the termination in writing;
- the patient verbally agreeing to the termination (which is then documented); or
- the WYOMING COUNTY HEALTH DEPARTMENT informing the patient that the restriction is being terminated.
The WYOMING COUNTY HEALTH DEPARTMENT may only terminate the restriction with respect to PHI that the WYOMING COUNTY HEALTH DEPARTMENT generates after informing the patient of the termination.
H. The WYOMING COUNTY HEALTH DEPARTMENT will document (in accordance with F and G above) how the termination was achieved and how the patient was notified.
III. Request Confidential Communications – A patient has the right to restrict disclosures of information related to communications made by the WYOMING COUNTY HEALTH DEPARTMENT to the patient by allowing the patient to request that such communications be made to them at an alternative location or by an alternative means.
A. The WYOMING COUNTY HEALTH DEPARTMENT will accommodate all reasonable requests.
B. The WYOMING COUNTY HEALTH DEPARTMENT will use the following guidelines to assist us in determining the reasonableness of a request:
- the patient will not be required to provide a reason for the request as a condition of accommodating the request;
- if the patient indicates that the information will cause endangerment, the patient’s reason for making the request will not be considered, rather the request will be honored; and
- a request to accommodate will not be honored if the patient has not provided information as to how payment, if applicable, will be handled, or if the patient has not specified an alternative address or method of contact.
IV. Request Amendment – a patient has the right to request an amendment to their PHI or a record about them in a designated record set for as long as the PHI is maintained in the designated record set.
A. The WYOMING COUNTY HEALTH DEPARTMENT may deny a request for amendment if:
- the PHI was not created by the WYOMING COUNTY HEALTH DEPARTMENT, unless the patient provides a reasonable basis to believe that the originator is no longer available to act on the requested amendment;
- the requested PHI is not part of the designated record set; or
- the PHI is accurate and complete.
B. The WYOMING COUNTY HEALTH DEPARTMENT will (in advance) require that the request for amendment be in writing and that a reason to support the requjest be provided by the patient making the request.
C. The WYOMING COUNTY HEALTH DEPARTMENT will act on the request within 60 days. The WYOMING COUNTY HEALTH DEPARTMENT may extend action on the request by no more than 30 days if, within the 60 days, the WYOMING COUNTY HEALTH DEPARTMENT provides a written statement of the reason(s) for the delay and the date by which action will be taken. No more than on 30 day extension is permitted.
D. if the requested amendment is accepted, in whole or in part, the WYOMING COUNTY HEALTH DEPARTMENT will:
- make the amendment to the PHI or record that is the subject of the request, and, at a minimum, identify the records in the designated record set that are affected by the amendment by appending or linking it to the location of the amendment;
- inform the patient in a timely fashion and obtain their identification of and agreement to have the WYOMING COUNTY HEALTH DEPARTMENT share the amendment as follows:
- to persons identified by the patient as having received PHI about the patient and needing the amendment;
- to persons, including business associates, that are known to have the PHI that is the subject of the amendment and that may have relied (or could in the future) on such information to the detriment of the patient.
E. If the requested amendment is denied, in whole or in part, the WYOMING COUNTY HEALTH DEPARTMENT will:
1. provide a statement of denial which will include:
- the basis for the denial;
- the patient’s right to submit a written statement disagreeing with the denial and how the patient may file such a statement;
- a statement that, if the patient does not submit a statement of disagreement,that patient may request that the WYOMING COUNTY HEALTH DEPARTMENT provide the patient’s request for amendment and the denial with any future disclosure of the PHI that is the subject of the amendment; and
- a description of the complaint process, for both the WYOMING COUNTY HEALTH DEPARTMENT and the Secretary of DHHS, to include name, title, telephone and other contact information
2. permit the patient to submit a written statement disagreeing with the denial and the basis for such disagreement;
3. if appropriate, provide a rebuttal statement to the patient’s statement of disagreement and provide a copy to the patient;
4. identify the record or PHI in the designated record set that is the subject of the disputed amendment and append or link, for the purpose of record keeping, the documents related to the denial.
F. The WYOMING COUNTY HEALTH DEPARTMENT will provide either the material appended or the statement of disagreement (and related documents) in any future disclosures of the PHI that the patient sought amended.
G. The WYOMING COUNTY HEALTH DEPARTMENT, when informed by another entity of an amendment to a patient’s PHI, will amend the PHI in the designated record set.
H. The WYOMING COUNTY HEALTH DEPARTMENT’S PRIVACY OFFICER is responsible for receiving and processing requests for amendments by patients and retention of the documentation.
V. Accounting for Disclosures- A patient has the right to request an accounting of all disclosures of his/her PHI if a disclosure was for a purpose other than treatment, payment, of health care operations and does not meet one of the following exceptions:
- prior to the effective date of the rule (April 14, 2003);
- to law officials or correctional institutions;
- for facility directories, if applicable;
- to the patient;
- for national security or intelligence purposes;
- to people involved in a patient’s care; and
- for notification purposes
The WYOMING COUNTY HEALTH DEPARTMENT must temporarily suspend the patient’s right to accounting of disclosures when a health oversight agency or law enforcement official provides the WYOMING COUNTY HEALTH DEPARTMENT with a written statement that such an accounting would be reasonably likely to impede the agency’s activity and specifies the time period that the suspension is required. The WYOMING COUNTY HEALTH DEPARTMENT must also temporarily suspend the patient’s rights to accounting of disclosure when the health oversight agency or law enforcement agency or law enforcement officials requires the suspension by verbally requesting it. In the case of a verbal request, the suspension is limited to 30 days unless appropriate written documentation is submitted withing 30 days.
- The WYOMING COUNTY HEALTH DEPARTMENT will keep a history of when and to whom disclosures of PHI are made for purposes other than treatment, payment, or healthcare operations. An accounting of these disclosures will be provided to the patient, if requested.
- The WYOMING COUNTY HEALTH DEPARTMENT will retain accounting of disclosures forms for six (6) years.
- Requests can be made for an accounting of disclosures for a period of up to six (6) years prior to the date of the request.
- The WYOMING COUNTY HEALTH DEPARTMENT will provide an accounting of disclosures withing 60 days of the request. If the WYOMING COUNTY HEALTH DEPARTMENT provides an explanation to the patient and a date for completion, one extension of 30 days is permitted.
- The accounting of disclosures will be maintained either electronically or on paper and will include:
- date of disclosure;
- name of recipient of information and address, if available;
- written accounting provided to a patient requester;
- description of information disclosed;
- titles and names of the people responsible for receiving and processing accounting requests.
- Summary disclosures may be used if there are recurring disclosures to the same entity of patient that have a regular interval. The summary must include all the information required above.
- One accounting per 12-month period will be provided free-of charge. Thereafter, the WYOMING COUNTY HEALTH DEPARTMENT may charge patients the reasonable cost(s) of providing the accounting. The patient will be notified of the charge and given the opportunity to withdraw their request in order to avoid the cost.