If the request to amend is granted, then the Department shall, within a reasonable time frame,

·          make the amendment

·          inform the individual that the amendment has been made, and

·          notify him or her of the relevant persons with whom the amendment must be shared, including

•   persons identified by the individual as having received the PHI and in need of the amendment, and

• professional providers who have previously received the PHI and have relied on the information.

The designated privacy staff shall ensure that a granted request for the amendment is acted upon within sixty (60) days of receipt.  

If this is not possible, the designated privacy staff shall notify the individual that the Department will avail itself to a thirty (30) day extension to respond.

The designated privacy staff shall identify the origin of the PHI requested to be amended.

·          If the Department is the originator of the PHI, then the designated privacy staff shall notify the individual in writing if the request for amendment has been granted or denied in whole or in part.

·          If the PHI originated with a source other than the Department, then the designated privacy staff shall direct the individual to that source, if known by the Department.

The designated privacy staff shall ensure that the amendment is made and documented in the record. The designated privacy staff shall notify the individual that the amendment has been made.

The Department shall deny  request(s) for amendment if it has determined that the PHI is accurate and complete.

Additionally, requests for amendments shall be denied if subject to any of the following:

·          The Department did not create the PHI, unless there is reasonable basis to believe that the person who created the PHI is no longer available to act on the requested amendment.

·          The PHI is not part of the record.

·          The PHI is information relevant to civil, criminal, or administrative actions.

·          The PHI is information subject to laws governing laboratory research.

·          The PHI is gathered in the course of research and the individual has agreed to denial of access until the completion of research.

·          The PHI was obtained from someone other than a Department employee under a promise of confidentiality and the Department believes the amendment may reveal the source of the information.

·          A licensed healthcare professional has determined, in the exercise of professional judgment, that the request is reasonably likely to endanger the life or physical safety of the individual or another person.

·          The PHI makes reference to another person and a licensed healthcare professional has determined, in the exercise of professional judgment, that the request is reasonably likely to cause substantial harm to such other person.

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

If a request for an amendment has been denied, then the designated privacy staff shall

·          provide a denial to the individual in writing or any other format that shall accommodate for the reading, writing or sight impaired and in a language other than English, if requested, to inform him/her why the request was denied

·          inform the individual of any rights to submit a written statement disagreeing with the denial of all or part of a request and the basis for such disagreement

·          inform the individual on how to make a complaint to the Department or to the Department of Health and Human Services

·          file the statement of disagreement in the Uniform Case Record

·          ensure that any future disclosure of the PHI that is the subject of the amendment includes the individual’s disagreement and the denial of the request. 

The denial letter 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