TELECARE CORP HIPAA AND THE AMENDMENT PROCESS Updated 11/17/09

HIPAA AMENDMENT TO RECORDS CALIFORNIA HEALTH & SAFETY CODE –Addendum To Records. Other states specify if any related requirement

OBJECTIVES  Identify the right to amend protected health information  Identify requirements for written amendment/correction to any item/statement in the health or other record of the Designated Record Set

OBJECTIVES -2  Spell out what and when information is required to be provided to a business associates  Indicate right to file a complaint with the covered entity and/or the Secretary of the Department of Health and Human Services, Office of Civil Rights;

OBJECTIVES -3  Identify additional rights, i.e. to file a complaint with the covered entity and/or the Secretary of the Department of Health and Human Services, Office of Civil Rights; -- &--  Decision re: the amendment request.

WHEN I GET A REQUEST  REQUEST to make amendment/correction to a designated record set/clinical record. What do I do ???? If you are a line staff – refer to the Supervisor. Supervisor – Department Head – Program Director – make the request form available to the patient to complete the request for amendment.

USE THE REQUEST FORM  See the example and provide that form to be completed.  Assure the timeliness of reporting and communication within the organization and with the resident.

AMENDMENTS  Let’s review the requirements and what the Policy and Procedure says.

POLICY  Rights of resident/patient/representative Have covered entity amend PHI Provide a written amendment/correction to any item/statement in the Designated Record Set Have the amendment be released with any future disclosures of records File a complaint with appropriate authority Receive timely denial notice & right to submit a disagreement statement

TIME FRAME – Privacy Officer  Notification of the Right to Amend Request to amend Response 60 days after receipt Program (Covered Entity) may extend (1 extension each time) Add 30 days if written Statement given if delay & date of decision

THE PROGRAM  Will NOT: Require to determine the accuracy or completeness of amendment Expunge any PHI

THE PROGRAM -2  Will: Reserve the right to deny any amendment Accommodate reasonable requests to receive amendments of PHI by other means/locations Need a written Request for Amendment for each alleged unclear/incomplete/incorrect item

AMENDMENT IS ACCEPTED  If request is granted, the program will: Insert the amendment or provide a link Inform the individual that the amendment is accepted Obtain the consent to have amendment shared with applicable individuals Make reasonable efforts to notify business associates, including anyone could foreseeably rely on such information

CRITERIA FOR DENIAL  Amendment is not created by the organization  Information is not part of the designated record set  Information is not available for inspection  Information is accurate and complete  Adequate verification of identify was not provided

ADDENDUM  California does NOT give an individual the right to request an amendment to PHI.  California DOES give an individual the right to have a written addendum included in the medical record per California law (Health & Safety Code )

OTHER STATES  Specify if there is something that is unique to your state: (remember HIPAA has priority unless your state is more restrictive).

PROCEDURE  Staff member receiving the request to amend will notify the appropriate program designated persons  Designated persons will: Obtain written request to amend record by providing a blank Request to Amend Personal PHI for completion or obtaining a completed form from the individual

PROCEDURE -2  Designated persons will (cont.): Send the completed form to the original author of the comment Upon return of the form, acceptance/denial will be facilitated with the author’s comments Forward the form and the determination of the acceptance/denial with author’s comment to requesting individual Keep track of amendment requests

AMENDMENT IS ACCEPTED  Timely notify the individual in writing that amendment has been accepted  Provide the individual a copy of the completed amendment/correction  Place a copy in the record and identify/provide a link to the affected record set

AMENDMENT IS ACCEPTED -2  Inform others via: Send a copy of the amendment to the original entry’s author If author adds a comment, copy will be routed to individual Original amendment return to program to be filed with the original entry in the individual’s record Continue with the amendment process

AMENDMENT IS ACCEPTED -3  Forward a copy to: Individuals/organizations specified by the resident/patient Persons/organizations or business associates that foreseeably could rely on the information  Record disclosures on the amendment form including names, addresses of any additional disclosures, sign, title and date.

AMENDMENT IS ACCEPTED -4  When an amendment form is executed, make the entry at the site of the information being amended and indicate “see amendment/correction” Attached the amendment/correction  Include a copy of the amended/corrected entry to accompany the original entry each time the information is used/disclosed

CORRECTION OF ENTRY  If original author wishes to correct his/her documentation: Enter the word “Correction” next to the entry Identify the request for amendment/correction or provide a link Enter the date Refer to the corrected entry by date (i.e., Amendment/Phys Progress Notes, mm/dd/yy) Notify the Health Information Department

AMENDMENT IS DENIED  Timely provide a written denial and inform the individual of the denial  Indicate basis for denial  Inform the individual of his/her right: Submit a statement of disagreement File the statement of disagreement or request the program provide the request with any future disclosure

AMENDMENT IS DENIED -2  Inform the individual of his/her right: The program may place in the record why it does not agree with the disagree statement; if so, the program will provide a copy to individual To complain to the Office of Health & Human Services, Office of Civil Rights Name/Title and telephone number of the contact who handles complaints at the program

AMENDMENT IS DENIED -3  Program will: Prepare a written rebuttal to the individual’s statement of disagreement if desired. If one is prepared, a copy must be provided to the individual who submitted the statement of disagreement Include statements of disagreement with amendment denials or accurate summaries of the information in the rebuttal statements

PRIVACY OF HEALTH INFORMATION  It is your responsibility to assure residents rights are protected when they do request to amend their health record and that you take it seriously and make the appropriate notifications.

RESOURCES  Summary of key points  Revised Telecare policy/procedure and forms # Amendment HIPAA/Addendum to Records  California Health & Safety Code-#7009P

HIPAA AMENDMENT LET’S REVIEW …

QUESTION #1  Who can process a request to make an amendment/correction to a designated record set/clinical record? Health Information/Record Director/designee HIPAA Privacy Officer/Administrator Any facility’s Personnel

QUESTION #2  The program will delete any information determined to be incorrect?

QUESTION #3  If request is accepted, notify the individual ________, provide a copy, and ________ the original. By telephone, destroy the record In person, separate the amended record In writing, file the amended record

QUESTION #4  What does the individual submit once he/she has been notified of a denial in writing? Statement of Disagreement Accepts, no response needed 2 nd Request for Amendment

QUESTION #5  Who is responsible for health information privacy when requests for amendment to records are made? YOU