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Insert Agency Name and Address

______

XYZ Agency includes XYZ Children's Center, XYZ Work Scholarship Connection, XYZ Children’s Foundation & Corporation, & XYZ Therapeutic Foster Care Program.

Amendment or Correction of Clinical Information from a Client/Family Request

  1. References:

45 C.F.R. Sections 160-164Privacy Act of 1974

JCAHO IMPublic Health Law Section 18

Mental Hygiene Law 33.13, 33.16Public Officers Law, Article 6-A.

NYCRR Title 14 Part 520Public Law 104-191 Part 164.524

NYCRR Title 18 Parts 339, 340

II. XYZ Agency’ Purpose Statement and Definitions:

  1. This policy and procedure define the process for qualified individuals and/or the personal representatives to amend/correct their XYZ clinical record(s).
  1. Definitions: Please refer to the Glossary for XYZ Policies and Procedures.
  1. XYZ Agency’ Policy:
  1. Applicability: This policy and procedure applies to XYZ Agency inclusive of the affiliates identified above.
  1. Notifications & Special Considerations: Special Notifications & Considerations apply to the use, disclosure and access to PHI and clinical records. Please refer to the XYZ Regulatory Policy and Procedure Cover Sheet for a list. If there are any questions, please call the Privacy Officer and/or a Clinical Information Specialist (CIS) for clarification.
  1. Verification: Please refer to the XYZ Regulatory Policy and Procedure Cover Sheet for methods of verification.
  1. Educational Records are open records and clients and their parents have open access to these as established by the Family Educational Rights and Privacy Act (FERPA).
  1. XYZ Agency’ Procedures:
  1. After having access to PHI and the clinical record, the client and/or their personal representative may challenge (in writing) the accuracy of information maintained in the clinical record and may require that a brief written statement prepared by him/her concerning thechallenged information be inserted into the clinical record. The Documentation of Amendment or Correction to a Clinical Record Request form # should be used.
  1. Making the request:
  1. The written request must specifically refer to the information in question;
  2. Client name;
  3. Date of Birth;
  4. Document to be considered for amendment/correction;
  5. State if the correction is:

a)A typographical or spelling error;

b)Incorrect demographic information; or

c)Regarding the content within the document; and

  1. Reason for the request.
  2. If the individual and/or personal representative is unable to make the request in writing, staff will assist the individual in doing so.
  3. Requests should be sent to the Privacy Officer.
  1. Responding to the request:
  1. Upon receipt, the Privacy Officer, will write the date received in the top right corner of the request and enter their name on the “Request for Information Log Sheet” located on the CIS Info drive on the computer.

ii. The Privacy Officer will look the client up on the agency client database and forward the request to the applicable Clinical Information Specialist (CIS) and if necessary, the author of the document.

  1. XYZ has 10 business days from the day of receipt to respond, indicating they have received the request. The Acknowledgement of Request for an Amendment or Correction of a Clinical Record form # should be utilized at this time.
  2. The staff who received the request, should review it for the following information:

a)Valid signature from the qualified individual and/or their personal representative.

b)Specific information to be reviewed. If the request is vague, staff should follow up with the requestor for clarification.

c)Dates of signature must be within 90 days of the request.

  1. CIS staff should look the client up on the agency client record database. Records for affiliates may be located in different areas.
  2. All communications in writing, copies, faxes, etc…will include a cover letter as evidence of communication.
  3. The CIS staff will contact the current Service Provider, if necessary and the author of the document(s) in question in writing using the Notification To Clinician For Request for Amendment or Correction to a Clinical Record form #.
  4. Upon receipt of the request, the author of the document(s) will review the request.
  5. In all cases (whether the request has been approved or denied) the document(s)/record(s) in question shall be identified and shall append or otherwise link:

a)the request for the amendment or changes

b)XYZ’s decision;

c)(if a denial) the requestor’s statement of disagreement, if any; and

d)(if a denial) XYZ’s response, if any.

  1. Any changes and/or amendment in addition to any supporting information shall become a permanent part of the clinical record and shall be released whenever the clinical record/document at issue is released.
  2. If a subsequent disclosure is made using a standard transaction that does not permit the additional material to be included, XYZ may separately transmit the material required.
  3. If XYZ is informed by another CE (covered entity) of an amendment to a clinical record or documents therein, XYZ must amend the document(s)/record(s) in question in written or electronic form.
  1. Approval and Denials:
  1. Determination will be made if the request is approved as submitted, or a written summary of the requestor’s comments/concerns is attached to the document(s).
  2. All notifications of approvals or denials will be in writing, on the Acknowledgement of Request for an Amendment or Correction of a Record form #.
  3. All decisions will be made within 30 days of receipt of the request.
  4. Requests for correction of typographical errors, misspelled words, names or date corrections will be expedited quickly without need of review by Service Providers as determined by CIS.
  5. For all approvals:

a)the requestor must be informed of the acceptance;

b)obtain the requestor’s identification of and agreement to have XYZ notify the relevant person(s) with whom the amendment needs to be shared;

c)within 30 days of approval, XYZ must make reasonable efforts to provide the amendment to persons identified by the individual, and persons, including business associates, that XYZ knows have the document(s) in question and that may have relied on or could potentially rely on the information.

  1. Approvals of requests as requested:

a)If the request is approved as requested, and the request is typographical, incorrect demographic information or spelling errors, the requestor will be notified of the changes and CIS will be responsible for noting the amendment/correction in the clinical record.

b)If the request is approved as requested and it is related to clinical content changes in the document(s), the author of the document or someone of similar title (if the author is no longer available) will amend the document and the requestor will be notified of the changes.

  1. Denials:

a) Determination to deny the request for amendment or correction may be made if the information:

1)was not created by XYZ, unless the originator is no longer available to act on the request;

2)is not part of the clinical record (as defined by XYZ Designate Record Set Policy and Procedure);

3)would not be accessible due to the following reasons:

  • constitute psychotherapy notes;
  • the information was compiled in anticipation or use in a civil, criminal, or administration action or proceeding;
  • the records are subject to the Privacy Act of 1974 and the denial of access meets the requirements of that law;
  • the clinical information was obtained from someone other than a healthcare provider under a promise of confidentiality and access would likely reveal the source of the information.
  • Other exceptions warranted by state and federal privacy and confidentiality laws (for further information consult with the Privacy Officer or CIS).

4)is accurate and complete.

b) Denied requests: XYZ must provide the requestor with a timely, written denial that states:

1)the basis for the denial;

2)the requestor’s right to submit a written statement disagreeing with the denial and how the requestor may file such a statement;

3)a statement that if the requestor does not submit a statement of disagreement, the requestor may request XYZ provide the requestor’s request for amendment and the denial with any future disclosures of the document(s) in question.

4)a description of how the requestor may complain to XYZ, the Office of Civil Rights (OCR), and the respective oversight agency per the service of delivery (e.g., OMH, OMRDD, DSS) (put link here);

5)the name, title, and telephone number of the agency Privacy Officer and/or Customer Satisfaction Line (put link here).

c) Appeals: For denials of access, the requestor must be supplied with the steps to be taken to initiate an appeal, of the address and phone number of the appropriate agency which can be located on the web (put link here);

  1. A Summary of Disagreement Statement:

a)If the summary statement is completed, it shall become a permanent part of the record and shall be released whenever the clinical record/document at issue is released.

b)The requestor must be permitted to submit a written statement of disagreement with the denial of all/part of a requested amendment and the basis of such a disagreement.

c)XYZ reserves the right to reasonably limit the length of a statement of disagreement.

d)XYZ may prepare a written response to the requestor’s disagreement. If a response is prepared, XYZ must provide a copy to the person who submitted the disagreement statement.

XYZ Amendment 2/27/03 ml

Insert Agency Name and Address

______

XYZ Agency includes XYZ Children's Center, XYZ Work Scholarship Connection, XYZ Children’s Foundation & Corporation, & XYZ Therapeutic Foster Care Program.

Documentation of Amendment or Correction to a Clinical Record Request form

Client Name:Date of Birth: Id Number:

Address:

Phone Number:

Date, Type & Author of Entry to be Amended:

Please explain how this entry is incorrect or incomplete. What should the entry say to be more accurate or complete?

Additional Comments:

We will make a best effort to forward your amendment or correction to other providers who may have received this from us in the past. This amendment or correction will become a part of the clinical record and will be forwarded to any other service providers who may request this document in the future.

For XYZ Agency Use Only:

Date Received Amendment has been:  Approved  Denied

If denied, check reason for denial:

PHI was not created by XYZ or its affiliatesPHI is not part of the clinical record

PHI is not available to the client/requestor for inspection as allowed/required by law

PHI is accurate and complete

Comments:

Staff Signature (Name & Title): Date:

Form # 2/27/03

ACKNOWLEDGEMENT OF REQUEST FOR AN

AMENDMENT OR CORRECTION OF A RECORD

Insert Agency Name and Address

______

XYZ Agency includes XYZ Children's Center, XYZ Work Scholarship Connection, XYZ Children’s Foundation & Corporation, & XYZ Therapeutic Foster Care Program.

Date:

Dear :

This letter is to acknowledge your request for amendment or correction of the clinical document(s)/record(s) of

Your request has been:

Approved (see #1 below)

Denied (see #2 below)

Is under consideration and a decision will be made by ______(Date is within 30 days of the date of this letter)

1. The amendment or correction will be provided to any person or governmental unit to whom the record has been or will be disclosed, provided that an accounting of such disclosure has been maintained in the record.

2. The reason for denial of your request is as follows:

The agency does not have possession of the record.

The requested record cannot be retrieved by the description given. Please provide the following information:

The agency cannot locate the record after having made a diligent search.

The responsible clinician does not feel that an amendment or correction is warranted.

Constitute psychotherapy notes.

The information was compiled in anticipation or use in a civil, criminal, or administration action or proceeding.

The records are subject to the Privacy Act of 1974 and the denial of access meets the requirements of that law.

The clinical information was obtained from someone other than a healthcare provider under a promise of confidentiality and access would likely reveal the source of the information.

The information has been reviewed and is considered accurate and complete.

You have the right to disagree or appeal this decision. You have 30 days from the date of this letter to do so. All appeals must include the following information:

The date and location of the request for amendment or correction.

The record that is subject to the appeal.

An explanation of disagreement or reason for appeal.

The name and return address of the appellant.

If you choose not to submit a statement of disagreement, you may request that we attach your request for amendment or correction to any future disclosures of the document(s)/record(s) in question.

Appeals or complaints can be sent to: ______

Privacy Officer

XYZ Agency

1234 Main Street

City, GA 00000

(404) 123-4567 or (770) 987-6543 fax or via e-mail

You may also send appeals to: insert proper name & address of external contact.

Please Note: The pursuit of an appeal or disagreeing with the decision will not condition current or future services and treatment.

Thank you,

(Name and title under your signature)

Amend acknowledgement form #

2/27/03 ml

Insert Agency Name and Address

______

XYZ Agency includes XYZ Children's Center, XYZ Work Scholarship Connection, XYZ Children’s Foundation & Corporation, & XYZ Therapeutic Foster Care Program.

NOTIFICATION TO CLINICIAN FOR REQUEST FOR AMENDMENT OR

CORRECTION TO A CLINICAL RECORD

Date:

Dear (Service Provider):

A request for amendment or correction to a clinical record has been received for ______.

The record is located ______.

Please make an appointment to meet with the Clinical Information Specialist Team to review this record so that appropriate action can be taken.

A decision must be given to the requestor by ______, so please follow-up as soon as possible so that the procedure can be followed in a timely fashion.

If you have any questions, please feel free to call Clinical Information at 000-0000.

Sincerely,

Mary Smith

Clinical Information Specialist

Amend notification ltr

2/27/03 ml