(A) Overview.
(1) The Privacy Officer manages the access and denial process. Patients have a right to inspect and receive a copy, at their expense, of the protected health information (PHI) in their designated record set. Exceptions to this include: psychotherapy notes, information compiled in anticipation of or use in a civil, criminal, or administration action or proceeding, and protected health information (PHI) subject to the Clinical Laboratory Improvements Amendments (CLIA) of 1988.
(2) All workforce members must strictly observe the following standards.
(B) Procedure for PHI access.
(1) A patient has the right to inspect, or receive copies of PHI about the patient in a designated record set for as long as the PHI is maintained in the designated record set.
(2) If the department or the village does not maintain the PHI that is the subject of the patient's request for access, and the department or the village knows where the requested information is maintained, the department or the village must inform the patient where to direct the request for access.
(3) The patient must make the request in writing.
(4) The department or the village must act on the patient's request no later than the 30th business day after receipt and payment of the request. The department or the village shall:
(a) Make the information available, in full or in part, for examination; or inform the authorized requestor if the information does not exist, cannot be found, or is not yet complete. Upon completion or location of the information, the department or the village will notify the patient.
(b) If the access is granted, in whole or in part, the department or the village must comply with the following requirements:
1. The department or the village must provide the patient access to his or her PHI in the designated record sets, including inspection or receiving a copy, or both. If the same PHI that is the subject of a request for access is maintained in more than one designated record set or at more than one location, the department or the village need only produce the PHI once in response to a request for access.
2. The department or the village must provide the patient with access to the PHI in the form or format requested by the patient, if it is readily producible in such form or format; or, if not, in a readable hard copy form or such other form or format as agreed to by both parties.
(5) The department or the village may provide the patient with a summary of the PHI requested, in lieu of providing access to the PHI or may provide an explanation of the PHI to which access has been provided, if:
(a) The patient agrees in advance to such a summary or explanation; and
(b) The patient agrees in advance to the fees imposed, if any, by the covered entity for such summary or explanation.
(6) The department or the village must provide the access as requested by the patient in a timely manner, including arranging with the patient for a convenient time and place to inspect or receive a copy of the PHI, or mailing the copy of the PHI at the patient's request.
(7) The department or the village may discuss the scope, format, and other aspects of the request for access with the patient as necessary to facilitate the timely provision of access.
(8) If the patient requests a copy of the PHI or agrees to a summary or explanation of such information, the department or the village may impose a reasonable, cost-based fee, provided that the fee includes only the cost of:
(a) Copying, including the cost of supplies for and labor of copying, the PHI requested. The fee schedule for these services is the reimbursement of the cost therefor;
(b) Postage, if the patient has requested the copy, summary, or the explanation is mailed. The fee schedule for postage can be obtained from the department or the village; and
(c) Preparing an explanation or summary of the PHI, if agreed to by the patient.
(C) Procedure if PHI access is denied.
(1) The department or the village must allow a patient to request access to inspect or receive a copy of PHI maintained in their designated record set. However, the department or the village may deny a patient's request without providing an opportunity for review when:
(a) An exception detailed above in the policy statement exists;
(b) The department or the village is acting under the direction of a correctional institution and the prisoner's request to obtain a copy of PHI would jeopardize the patient, other prisoners, or the safety of any officer, employee, or other person at the correctional institution, or a person responsible for transporting the prisoner;
(c) The patient agreed to temporary denial of access when consenting to participate in research that includes treatment, and the research is not yet complete;
(d) The records are subject to the Privacy Act of 1974 and the denial of access meets the requirements of that law; the PHI was obtained from someone other than the department or the village under a promise of confidentiality and access would likely reveal the source of the information.
(2) The department or the village may also deny a patient access for other reasons, provided that the patient is given a right to have such denials reviewed under the following circumstances:
(a) The department or the village or a licensed health care provider designated or appointed by the department or the village has determined that the access is likely to endanger the life or physical safety of the patient or another person;
(b) The PHI makes reference to another person who is not a health care provider, and the department or the village or a licensed health care professional designated or appointed by the department or the village has determined that the access requested is likely to cause substantial harm to such other person;
(c) The patient's surrogate decision maker makes the request for access and the department or the village or a licensed health care professional designated or appointed by the department or the village, has determined that access is likely to cause substantial harm to the patient or another person.
(3) If access is denied on a ground permitted above, the patient has the right to have the denial reviewed by the department or the village or a licensed health care professional designated or appointed by the department or the village to act as a reviewing official, and who did not participate in the original decision to deny. The department or the village must provide or deny access in accordance with the determination of the reviewing official.
(4) If the department or the village denies access, in whole or in part, to PHI, the department or the village must comply with the following requirements:
(a) The department or the village must, to the extent possible, give the patient access to any other PHI requested, after excluding the PHI to which the department or the village denied access.
(b) The department or the village must provide a timely, written denial to the patient, in plain language and containing:
1. The basis for the denial;
2. If applicable, a statement of the patient's review rights, including a description of how the patient may exercise such review rights; and
3. A description of how the patient may complain to the department or the village pursuant to the department or the village's complaint policy.
(5) If the patient has requested a review of a denial, the department or the village must designate or appoint a licensed health care professional, who was not directly involved in the decision to deny access. The department or the village must promptly refer a request for review to such licensed health care professional. The licensed health care professional must determine, within a reasonable period of time, whether or not to deny the access requested based on the aforementioned procedures and standards. The department or the village must promptly provide written notice to the patient of the findings of the reviewing licensed health care professional, and take other action as required by this section to carry out the licensed health care professional's determination.
(D) Enforcement. The department's Privacy Officer is responsible for enforcing this policy, and shall be entitled to the assistance of the Village Manager in doing so, if such assistance should be needed. Individuals who violate this policy will be subject to the appropriate and applicable disciplinary process under this policy and the applicable ordinances of the village, up to and including termination or dismissal.
(Ord. 0030-03, passed 4-2-03)