(A) Patients have a right to amend information collected and maintained about them in their designated record set. All personnel must strictly observe the following standards.
(B) An individual has the right to have the department and the village amend PHI or a record about the individual in a designated record set for as long as the PHI is maintained in the designated record set.
(C) The department and the village may deny an individual's request for amendment, if it is determined that the PHI or record that is the subject of the request:
(1) Was not created by the department and the village, unless the individual provides a reasonable basis to believe that the originator of the PHI is no longer available to act on the requested amendment;
(2) Is not part of the designated record set;
(3) Would not be available for inspection under this policy; or
(4) Is accurate and complete.
(D) The individual must make the request to amend the PHI in writing with a reason to support a requested amendment. The request should be on a form as set forth in § 5 of this policy.
(E) The department and the village must accept all requests to amend PHI in the designated record set; however, the department and the village are not required to act on the individual's request if it is in accordance with subdivisions (C)(1), (2), (3) or (4) above.
(F) The department and the village must act on the individual's request for an amendment no later than 60 days after receipt of such a request. If the department and the village is unable to act on the amendment within the required 60 day time limit, the department and the village may extend the time for such action by no more than 30 days, provided that the department and the village provides the individual with a written statement of the reasons for the delay and the date by which action on the request will be completed and the department and the village may have only one such extension of time for action on a request for an amendment.
(G) If the amendment is granted, in whole or in part, the department and the village must make the appropriate amendment to the PHI or record that is the subject of the request for amendment by, at a minimum, identifying the records in the designated record set that are affected by the amendment and appending or otherwise providing a link to the location of the amendment. The department and the village must inform the individual in a timely manner that the amendment is accepted and obtain the individual's identification of and agreement to have the department and the village notify the relevant persons with which the amendment needs to be shared. The department and the village must make reasonable efforts to inform and provide the amendment within a reasonable time, to:
(1) Persons identified by the individual as having received PHI about the individual and needing the amendment; and
(2) Persons, including business associates, that the department and the village knows have the PHI that is the subject of the amendment and that may have relied on such information to the detriment of the individual.
(H) If the requested amendment is denied, in whole or in part, the department and the village must provide the individual with a timely, written denial. The denial must use plain language and contain:
(1) The basis for the denial;
(2) The individual's right to submit a written statement disagreeing with the denial and how the individual may file such a statement;
(3) A statement that, if the individual does not submit a statement of disagreement, the individual may request that the department and the village provide the individual's request for amendment and the denial with any future disclosures of the PHI that is the subject of the amendment; and
(4) A description of how the individual may complain to the department and the village or the Secretary of the Department of Health and Human Services (HHS) in accordance with this policy.
(I) Additionally for denials:
(1) The department and the village must permit the individual to submit a written statement disagreeing with the denial of all or part of a requested amendment and the basis of such disagreement.
(2) The department and the village may reasonably limit the length of a statement of disagreement.
(3) The department and the village may prepare a written rebuttal to the individual's statement of disagreement. Whenever such a rebuttal is prepared, a copy of the rebuttal must be provided to the individual who submitted the statement of disagreement.
(4) The department and the village must, as appropriate, identify the record or PHI in the designated record set that is the subject of the disputed amendment and append or otherwise link the individual's request for an amendment, the denial of the request, the individual's statement of disagreement, if any, and the rebuttal, if any, to the designated record set.
(J) If a statement of disagreement has been submitted by the individual, the department and the village must include the patient's request for an amendment, the denial of the request, the patient's statement of disagreement and the rebuttal, if any, or an accurate summary of any such information, with any subsequent disclosure of the PHI to which the disagreement relates.
(K) If the individual has not submitted a written statement of disagreement, the department and the village must include the individual's request for amendment and its denial, or an accurate summary of such information, with any subsequent disclosure of the PHI only if the individual has requested such action.
(L) When a subsequent disclosure is made using a standard transaction that does not permit the additional material to be included with the disclosure, the department and the village may separately transmit the material required to the recipient of the standard transaction.
(M) If the department or the village is informed by another provider or payer of an amendment they have made to an individual's PHI within the outside entities' designated record set, the department and the village must amend the PHI in designated record sets that have been received from those outside entities. However, the department and the village do not have to amend the PHI in the department and the village designated record set based upon an outside determination, unless the department and the village have relied on the outside entities' findings.
(N) Patients may request to have their PHI amended by submitting a Request for Correction/ Amendment of Protected Health Information Form as set forth in § 5.
(O) Once the department and the village make a decision regarding the request for amendment, the department and the village will send a final letter outlining the decision to the patient. If the decision is to amend, the department and the village will document the decision in a Medical Record Amendment/Correction Form.
(P) 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)