A client or the claimant’s personal representative who believes his or her health records are incomplete or incorrect may request an amendment or correction of the health records.
Do not consider information learned during the regular course of business to be an amendment. Examples include when a client provides the name of a new treating physician.
Additions to the file are not amendments.
- Minor discrepancies: For minor discrepancies such as typing errors, misspelled names, wrong dates, etc., staff may correct the entry by drawing a single line through the error, adding a note that explains the error, dating it, initialing it, and by making the correction as close as possible to the original entry in the record.
- All other requests: All other requests for amendment of PHI must be in writing and include the reason to support the amendment. The request should include any documentation that explains or verifies the incorrect or incomplete PHI that the client is requesting to amend. Have the client complete the DSS Request for Amendment/Correction of Protected Health Information form. The decision whether to grant the request must be approved or denied within 60 days. Based on the client’s request and information provided, determine whether to amend the PHI. Staff cannot approve the amendment if:
- FSD did not create the PHI unless the client provides a reasonable basis for staff to conclude that the originator of the PHI is no longer available to do the amendment; OR
- The PHI is not part of the client’s case records; OR
- The information is not available for the client’s inspection (See list of reasons to deny access per 0130.005.10.25 Client’s Right to Access Their Health Information on File in FSD Records); OR
- The information is accurate and complete.
- If staff approves the amendment request, take the following actions:
- Insert the amendment or reference the amendment to the site of the information that is the subject of the request for amendment, and then document the change in the same section of the record as the original information; AND
- Inform the individual that the amendment is accepted; AND
- Within 60 days, make reasonable efforts to provide the amendment to the persons identified by the client and any persons that staff knows that have been provided the PHI that is the subject of the amendment and who may have relied on or could possibly rely on the information to the detriment of the client.
- Denying Requests for Amendment of Protected Health Information: If staff believes that the request should be denied, immediately forward the form to the FSD Privacy Officer who will then forward it to the DSS Privacy Officer. Include the reason to deny the amendment and any documentation that explains or verifies the incorrect or incomplete PHI that the client is requesting to amend. The privacy officer may request an extension of 30 days by notifying the client in writing. If the amendment request is denied, the privacy officer notifies the client and staff, and explains the reason for the denial and provides other information.
- Client Disagrees with the Denial: The individual has the right to submit a written statement disagreeing with the denial of all or part of a requested amendment and the basis for the disagreement. Submit the written statement to the privacy officer. The departmental privacy officer may prepare a written rebuttal to the statement of disagreement and send it to the client and staff. If the client has submitted a statement of disagreement and the request for amendment was denied, staff must identify the PHI that is the subject of the disputed amendment. If staff discloses the disputed information, they must also include with the disclosure the client’s statement of disagreement, the denial of the request for amendment, and the privacy officer’s rebuttal statement if any, or an accurate summary of the information.
If the person has not submitted a written statement of disagreement, the individual may request that staff includes the request and the letter of denial with any subsequent disclosure of PHI.