4.3.C HIPAA/Privacy: Patient Rights - Amendment of PHI

  • POLICY:

    A patient has the right to request their medical record be amended.  Lister Healthcare Corporation may require the patient submit the request in writing and that the patient provide a reason to support the requested amendment.  Lister Healthcare must either accept or deny a patient's request within 60 days of the request. (164.526a1)

    PROCEDURE:

    Once a request to an amendment has been accepted:

    • Amendments to the record must be made within 60 days of request.
    • Patient will be informed of acceptance of amendment.
    • If a correction to a patient's record is to be made, Lister Healthcare Corporation will retain the original entry so that an adequate audit trail exists.
    • A correction/addition will be written in a separate note that is signed, dated and identifies the record affected by the amendment.
    • Lister Healthcare Corporation will make reasonable efforts to inform and provide the amendment within a reasonable time to:
      • persons identified by the patient as having previously received protected health information about the patient and needing the amendment; and
      • persons, including business associates of Lister Healthcare Corporation, that LHC knows have the protected health information that is the subject of the amendment and that may have relied, or could foreseeably rely, on the information to the detriment of the patient.(164.526c3)

    Once a requested amendment has been denied:

    • A written denial, within 60 days, to the patient.  The letter must be written in plain language and must state:
      • the basis of the denial;
      • the patient's right to submit a written statement disagreeing with the denial and how the patient may file the statement.
    • Grounds for a denial:
      • the provider believes that the record is accurate and complete.
      • access to the medical record has been denied for reasons set forth previously in this policy and procedure.
      • information is not part of a designated record set.
      • information was not created by provider.

    Future Disclosures Subsequent to a denial:

    Lister Healthcare Corporation will include the patient's request for amendment and initial denial, or an accurate summary of this information, with any subsequent disclosure of phi only if the patient has requested that this action be taken.  However, if the patient files a statement of disagreement, the statement and any rebuttal, together with the patient's request and its denial will be included in all future disclosures of the protected health information. (164.526d5)

    The following information must be maintained for at least 6 years and appended or linked to the information that is the subject of the amendment request:

    • the request for the amendment
    • the denial (if applicable)
    • the patient's statement of disagreement (if applicable)
    • the providers rebuttal to the statement of disagreement (if applicable)

    Revised 1/2016

  • Date Format: MM slash DD slash YYYY