Title
The University of North Carolina at Chapel Hill Health Record Correction/Amendment Policy
Approved by the University HIPAA Steering Committee
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 University units 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 University unit 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 University unit. Covered University units 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 department of the covered University unit in possession of the medical record.
The Health Information Management department of the covered University unit 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 University unit 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 University unit informs the individual by written statement of the reasons for the delay and the date by which the covered University unit will complete the action on the request.
If the request for amendment or correction is accepted
If the covered University unit accepts the requested amendment or correction, in whole or part, the covered University unit 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 University unit 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 University unit 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 University unit 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 University unit may respond. The covered University unit 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 University unit.