The Department shall give individuals the right to access, inspect, and/or obtain a copy of his/her PHI as maintained in a designated record set, except for the following information:

·          psychotherapy notes

·          information relevant to civil, criminal, or administrative actions, or

·          information subject to laws governing laboratory research.

The Department shall require individuals to provide the request for access in writing, as long as it informs individuals of this requirement. 

Requests shall be made to

·          the legal staff in the Regional Offices, or 

·          to the medical records staff in the Department’s facilities.

 If granted, the Department shall comply with the request as follows:

·          Access to PHI shall be given in a readable, hard copy or alternate format that shall accommodate for the reading, writing or sight impaired.

·          A summary or explanation of the PHI may be given in lieu of providing complete access and shall be translated in a language other than English if requested and agreed to by the individual.

·          Access shall be given in a timely manner by mutually convenient means.

If the Department does not maintain the PHI requested, but knows where it is maintained, then the Department shall inform the individual where to direct the request for access.  

If access to PHI has been denied, then the Department shall

·          provide the individual a timely denial, in writing or an alternate format which shall accommodate for the reading, writing or sight impaired, to inform him/her why the request was denied  

·          grant the individual’s request to the information requested except
 for what was denied, and

·          inform the individual of any rights for a review of the denial and a
description of how to make a complaint to the Department.

The notice shall include the contact’s name, title and telephone number for more information to address or file a complaint with the Department.

Cross-Reference: Policy 44-7-10, Complaint Process

The individual has the right to review a denial of access to a PHI under the following circumstances:

·          A Department employee who is also a licensed health care professional has determined, in the exercise of professional judgment, that the access requested is reasonably likely to endanger the life or physical safety of the individual or another person.

·          The PHI makes reference to another person (unless such other person is a health care provider) and a licensed health care professional has determined, in the exercise of professional judgment, that the access requested is reasonably likely to cause substantial harm to the person.

·          The request for access is made by the individual’s personal representative and a licensed health care professional has determined, in the exercise of professional judgment, that the provision of access to such personal representative is reasonably likely to cause substantial harm to the individual or another person.

The individual does not have the right to review a denial of access to a PHI under the following circumstances:

·          The individual has agreed to the denial of access when consenting to participate in research that includes treatment and the covered health care provider has informed the individual that the right of access may be reinstated upon completion of the research.

·          The individual’s access to PHI that is contained in records that are subject to the Privacy Act, 5 U.S.C. § 552a, may be denied, if the denial of access under the Privacy Act would meet the requirements of that law.

·          The PHI was obtained from someone other than a health care provider under a promise of confidentiality and the access requested would be reasonably likely to reveal the source of the information.

If the individual disagrees with the denial of access to PHI, then the individual may provide a written statement disagreeing with the denial of all or part of a request and the basis of such disagreement.

The Department shall provide a licensed healthcare professional, who did not participate in the original denial, to review the new request for review of the denial.

The Legal Division, in consultation with the Regional Resource Group, shall determine access to PHI in the regional offices.

Medical records staff shall determine access to PHI in Department-operated facilities.

The approval or denial of access to PHI shall occur within thirty (30) days of the request and shall be communicated to the individual in writing or other alternate format that shall accommodate for the reading, writing or sight impaired. It should also include the translation in a language other than English, if requested.

If the request for access is granted, then the designated privacy staff shall indicate the date, time and manner in which the access is granted.

If the Department does not maintain the PHI requested, then designated privacy staff shall direct the individual to the originator of the information, provided that the Department knows who originated the information.