Policy Manual

 
  1.MEP.22  

Amendment of Protected Health Information (client record) by a client      

Type: Procedure                 Category: General                 Level: Community Care 

Parties: Community Care Employees and Contractees

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Supporting References: See policy

Parent Effective Date Approval Level Revision Dates Last Reviewed
1.ME.10  4-13-2003  Executive Director    N/A
Related Document Code Related Document Name Type

Procedure:  All providers who receive a request by a client to amend any information within the client chart should notify their Supervisor and the agency Privacy Officer within 24 hours of the request. The Provider should also provide the phone number to the client where he or she may contact the agency Privacy Officer to discuss the process of amending information. Upon notification, The Privacy Officer will contact the client within three business days of the request and document required information regarding the request. After collecting the necessary information from the client, the Privacy Officer will, within five business days of speaking with the client, convene a meeting between the Provider who accepted the request, the Provider responsible for the maintenance of the Client Record, and the Clinical Supervisor of the case (MUST BE LICENSED). In establishing this meeting, other relevant treatment Providers within Community Care may be included. The request will be reviewed at this meeting and a decision made whether to grant or deny the request. If the request is granted, the Privacy Officer will, within five business days, notify the client by phone and in writing of the approval of the request. The Privacy Officer will obtain necessary information to process the approved amendment(s). The Provider responsible for the maintenance of the chart will amend the information per the approval and notify identified parties outside Community Care of the amended information. If the request is denied, the Privacy Officer will contact the client within five business days by phone and in writing notifying them of the denial and the reason(s) why. The Privacy Officer will provide the client with an opportunity to submit a written statement disagreeing with the decision. The Privacy Officer will, within five business days, review the written statement with the team who made the original decision and decide whether to write a rebuttal. If a rebuttal is written, the Privacy Officer will, within five business days, send a copy of the rebuttal letter to the client. All written documentation regarding the process will become a part of the client record.