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Any corrected record submitted must make clear the specific change made, the date of the change and the identity of the person making that entry. Note that only the attending providerthat is, the provider who saw the patient and documented the initial note for the visit in questionmay amend the medical record.
Just as a covered entity may not withhold or deny an individual access to his PHI on the grounds that the individual has not paid the bill for health care services the covered entity provided to the individual, a covered entity may not withhold or deny access on the grounds that the covered entity used the individual's
If the covered entity denies all or part of a requested amendment, the covered entity must permit the individual to submit to the covered entity a written statement disagreeing with the denial of all or part of a requested amendment . The patient may state the basis of the disagreement in the written statement.
The covered entity may deny the request if it determines that the PHI or record that is the subject of the request: Was not created by the covered entity (unless the originator is no longer available to act on the request; 45 CFR §164.526 (a)(2)(i)
For example, a covered entity may deny an individual access if the information requested is not part of a designated record set maintained by the covered entity (or by a business associate for a covered entity), or the information is excepted from the right of access because it is psychotherapy notes or information
(1) Right to amend. An individual has the right to have a covered entity amend protected health information or a record about the individual in a designated record set for as long as the protected health information is maintained in the designated record set. (iv) Is accurate and complete.
Reasons for Denial.The provider who received the amendment request had not created the original record. The record was created at another office. There is an exception if the creator is no longer available and the mistake in the record is apparent.
A covered entity is permitted, but not required, to use and disclose protected health information, without an individual's authorization, for the following purposes or situations: (1) To the Individual (unless required for access or accounting of disclosures); (2) Treatment, Payment, and Health Care Operations; (3)
General concerns about psychological or emotional harm are not sufficient to deny an individual access (e.g., concerns that the individual will not be able to understand the information or may be upset by it). In addition, the requested access must be reasonably likely to cause harm or endanger physical life or safety.
No. A patient's record should be complete and accurate to ensure they receive appropriate care. Patients can question the content of their records, but not on the basis that it is upsetting or that they disagree with it.