Standards for Requests to Amend Protected Health Information

1. Individuals must submit requests for amendment in writing.
2. Requests must use the designated "Request to Amend Protected Health Information form". These forms are managed by TXST healthcare components.
3. The form must include a detailed description of how the requestor would like the records amended and a reason supporting the requested amendment.

All requests must be directed to the HIPAA Privacy Custodian or designated staff responsible for managing and documenting HIPAA-related processes and within the required time. 

TXST shall act on the individual's request no later than sixty (60) days after receipt of the request. 

1. TXST may extend the time for action by no more than thirty (30) days.
2. If an extension is required, TXST must provide the individual with a written statement within the initial sixty (60) day period.
3. This statement must include the reasons for the delay and the date by which TXST will complete its action.
4. Only one such thirty (30) day extension is permitted. 

1. The determination to accept or deny the amendment will be coordinated by the HCC’s Privacy Custodian and approved by the original medical provider who created the record, Director or Chief Medical Officer
2. A request to amend Education records will be handled according to TXST UPPS 01.04.31 Access to Student Records Pursuant to the Family Educational Rights and Privacy Act of 1974.

1. The Privacy Custodian will conduct a review of the relevant record(s) and ensure they are records included in the HCC’s Designated Record Set.
2. Consultation with the treating physician and/or author of the entry requested to be amended and with the Director of the HCC is required.
3. An evaluation of the individual’s request will be performed.
4. Consultation with other health professionals familiar with the patient’s course of treatment may be included, to the extent appropriate. 

1. If TXST accepts the amendment, the appropriate amendment will be made to the PHI or record that is the subject of the request and notify the patient in a timely manner.
2. This involves identifying the records in the Designated Record Set affected by the amendment and appending or otherwise providing a link to the location of the amendment.
3. Work with the patient to obtain information on the persons with whom the amendment needs to be shared with and provide in a timely manner.
4. Review previous accounting of disclosures to determine if other parties have been provided PHI that was the subject of the amendment and provide them with the amended PHI. 

1. The amendment to the PHI may be in the form of an addendum or an actual change to the documentation in the record. Original documentation should never be obliterated.
2. If using an addendum, it should ideally be completed by the individual who made the original entry and placed in the same proximity as the original entry. 

Valid reasons to deny a request to amend PHI.

1. PHI is not a part of the Designated Record Set.
2. PHI was not created by the staff of the HCC, e.g. records from hospitals.
3. PHI is accurate and complete.
4. As described in § 164.524 (a)(2) and (a)(3), (review this section of the Privacy Rule) access of individuals to protected health information. 

Provide in writing and include the following:

1. The reason for the denial,
2. The right to submit a written statement disagreeing with the denial and how the individual my file such a statement, 
3. A statement that if the individual does not submit a statement of disagreement, the individual may request that the HCC provide the individual’s request for amendment and the denial with any future disclosures of the PHI that is the subject of the amendment and, 
4. A description of how the individual may file a complaint with the HCC or to the Secretary of HHS. The description must include the name or title of the HCC’s Privacy Custodian and telephone number. 

The individual must be permitted to submit a written statement disagreeing with the denial of all or part of a requested amendment and the basis of such disagreement. The HCC may reasonably limit the length of a statement. 

The HCC may prepare a written rebuttal to the individual’s statement. A copy must be provided to the individual.  

1. The HCC must include the statement and rebuttal, when a patient submits a Statement of Disagreement , or an accurate summary of any such information with any subsequent disclosure of the PHI to which the disagreement relates.  
2. The HCC must include the patient’s request for amendment and its denial, or an accurate summary of such information, with any subsequent disclosure of the PHI when the patient has requested such action.

1. HCC must make the necessary amendment to PHI in the DRS.
2. HCC must require a Business Associate who receives a notification to incorporate into any DRS it maintains for the HCC/CE.