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Title: Requests for Amendment of Protected Health Information
Subject: Office of Compliance & Corporate Integrity (OCCI)
Policy No:OCCI:2013:P05
Applies: RowanSOM
Issuing Officer: Chief Audit, Compliance & Privacy Officer
Responsible Officer: Director of Privacy and Investigations
Date Adopted: 07/01/2013
Last Revision:  03 01/3026/20202021
Last Reviewed: 03 01/3026/20202021

I.    PURPOSE PURPOSE

To establish guidelines for assuring that all Rowan University School of Osteopathic Medicine (RowanSOM) units that create designated record sets containing Protected Health Information (PHI) have a process to respond to patient’s requests for amendments of their individual health information.

II.     ACCOUNTABILITYACCOUNTABILITY

Under the direction of the President, Senior Vice President for Health Sciences, Dean, Associate Deans, Executive Director, Chief Audit, Compliance and Privacy Officer, Director of Privacy and Investigations and Vice President for Research shall ensure compliance with this policy.

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1. Responsibilities:
   1. The unit may deny the request if the health information that is the subject of the request meets the following conditions:
      1. It was not created by the unit, unless the originator is no longer available to act on the request.
      2. It is not part of the individual’s designated health record.
      3. It would not be accessible to the individual for the reasons under University policy, Access of Individuals to Protected Health Information.
      4. It is accurate and complete.
   2. The unit must act on the individual’s request for amendment no later than thirty (30) days after receipt of the request for an amendment. The unit may have a one - time extension of up to thirty (30) days for an amendment request provided the unit gives the individual a written statement of the reason for the delay, and the date by which the amendment will be processed.
   3. If the request is granted, the unit must:
      1. Insert the amendment or provide a link to the amendment at the site of the information that is the subject of the request for amendment.
      2. Inform the individual that the amendment is accepted.
      3. Obtain the individual’s identification of; and agreement to have the unit notify the relevant persons with whom the amendment needs to be shared.
      4. Within a reasonable time frame, make reasonable efforts to provide the amendment to persons identified by the individual, and persons, including business associates, that the unit knows have the PHI that is the subject of the amendment and that may have relied on or could foreseeably rely on the information to the detriment of the individual.
   4. If the unit denies the requested amendment, it must provide the individual with a timely, written denial in plain language that contains:
      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 unit, provide the individual’s request for amendment and the denial with any future disclosures of PHI.
      4. A description of how the individual may complain to the unit or to the Secretary of the Department of Health and Human Services (DHHS).
      5. The name or title, and telephone number of the designated contact person who handles complaints for the unit.
   5. The unit must permit the individual to submit to the unit a written statement disagreeing with the denial of all or part of a requested amendment and the basis of such disagreement. The unit may reasonably limit the length of a statement of disagreement.
   6. The unit may prepare a written rebuttal to the individual’s statement of disagreement. Whenever such a rebuttal is prepared, the unit must provide a copy to the individual who submitted the statement of disagreement.
   7. The unit must, as appropriate, identify the record of PHI that is the subject of the disputed amendment and append or otherwise link the individual’s request for an amendment, the unit’s denial of the request, the individual’s statement of disagreement, if any, and the unit’s rebuttal, if any.
   8. If a statement of disagreement has been submitted by the individual, the unit must include the material appended or an accurate summary of such information with any subsequent disclosure of the PHI to which the disagreement relates.
   9. If the individual has not submitted a written statement of disagreement, the unit must include the individual’s request for amendment and its denial, or an accurate summary of such information, with any subsequent disclosure of PHI only if the individual has requested such action.
   10. When a subsequent disclosure is made using a standard transaction that does not permit the additional material to be included, the unit may separately transmit the material required.
   11. A unit that is informed by another unit of an amendment to an individual’s PHI must amend the PHI in written or electronic form.
   12. A unit must document the titles for the persons or offices responsible for receiving and processing requests for amendments.

VII. NON-COMPLIANCE AND SANCTIONS

Any individual who violates this policy shall be subject to discipline up to and including dismissal from the University in accordance with their union and University rules.  Civil and criminal penalties may be applied accordingly.  Violations of this policy may require retraining and be reviewed with employee during the annual appraisal process. The Deans of each College, Vice Presidents, and University President, with the assistance of the Department of Human Resources, will enforce the sanctions appropriately and consistently to all violators regardless of job titles or level within the University and in accordance with bargaining agreements for represented employees. Any sanction costs or fines will be borne by the Department and the Department Chair or VP will determine how these funds will be assigned.

By Direction of the President:

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