Title
The University of North Carolina at Chapel Hill Policy on Health Record Correction and Amendment
Policy
Pursuant to the Health Insurance Portability and Accountability Act of 1996, as modified by the Health Information Technology for Economic and Clinical Health Act of 2009 ("HIPAA"), individuals have the right to request an amendment or correction to their medical information. Under specified circumstances, entities may deny the request to amend or correct an individual's medical information.
The University of North Carolina at Chapel Hill ("University") Covered Components will allow an individual to request an amendment to his/her medical information for as long as the information is maintained. Often, an individual's medical record maintained at a Covered Component may include medical information received from external sources that may be used to treat the individual. In that case, the individual must contact the external source directly to amend or correct that information and request that any such amendment or correction be provided to the Covered Component. Covered Components will not amend medical information in the designated record set of an individual from an external source unless the correction is provided by the external source or the individual provides a reasonable basis to believe the originator of the medical information is no longer available to act on the requested amendment and provides a reasonable basis for amendment and/or correction.
Procedure
The correction or amendment process
If an individual wishes to request a correction or amendment to medical information contained in his/her medical record, he/she must complete the attached Health Record Correction/Amendment Form and return the form to the Health Information Management ("HIM") department of the Covered Component in possession of the medical record.
The HIM department of the Covered Component holding the individual's medical record will inform the individual no later than 60 days after the individual's request if the amendment is denied. On occasions where the Covered Component needs more than 60 days to complete its review, the time period for the action will be extended by no more than 30 days, provided that the Covered Component informs the individual by written statement of the reasons for the delay and the date by which the Covered Component will complete the action on the request.
If the request for amendment or correction is accepted
If the Covered Component accepts the requested amendment or correction, in whole or part, the Covered Component will make the appropriate amendment or correction to the medical information and inform the requesting individual of acceptance of the amendment or correction. The Covered Component will obtain the individual's identification of and agreement to notify the relevant persons with whom the amendment or correction needs to be communicated. The Covered Component will make reasonable efforts to inform and provide the amendment within a reasonable time to such entities or persons identified by the individual.
If a request for amendment or correction is denied
Upon denying a request for an amendment or correction, in whole or part, the Covered Component will provide the individual with a written denial in accordance with the above timeframes. The individual may provide a written statement of disagreement, to which the Covered Component may respond. The Covered Component will provide the individual with a copy of the written response. All of the above, including the original request for amendment or correction, will be placed in the individual's medical record maintained by the Covered Component.