Section 19: Request to Amend Designated Record Set
A Patient has the right to request an amendment to the Patient’s PHI in a Designated Record Set. The Callier Center shall comply with any notice of amendment of PHI received from a Covered Entity that is the Center’s source of such PHI.
The Center shall permit a Patient or the Personal Representative of a Patient to make written requests for amendment of the Patient’s PHI contained in the Callier Center’s Designated Record Set, provided that the request includes a reason in support of the amendment. If a Patient either orally notifies the Center of his or her desire to request an amendment or does not include a reason in the written request, the Privacy Officer shall give the individual a copy of the form Request for Amendment of Protected Health Information included in the Appendix to this Manual, to facilitate the Patient’s ability to make a written, complete request. Request to Amend Form (English/Spanish)
Review of Request for Amendment
The Privacy Officer shall be responsible for receiving and processing requests for amendment of PHI by Individuals. The Privacy Officer shall have ultimate authority regarding whether such requests will be granted or denied. Upon receipt of a written request for amendment of PHI with a supporting reason, the Privacy Officer shall review the applicable portion of the individual’s PHI in the Designated Record Set and determine whether the request for amendment will be granted, in whole or in part. A request may be denied, in whole or in part, only under all or some of the following circumstances:
a. the PHI (or portion thereof) subject to the request would not be made available if the Patient had requested access to such PHI under the terms of Section 16 of this Manual;
b. the PHI (or portion thereof) subject to the request is not part of a Callier Center Designated Record Set;
c. the PHI (or portion thereof) subject to the request was not created by the Callier Center or a Business Associate, and the Patient has not provided a reasonable basis to believe that the originator of the PHI is no longer available to act on the requested amendment; or
d. the PHI (or portion thereof) subject to the request is currently accurate and complete.
Time Period for Responding to a Request for Amendment
The Center shall respond to a request for amendment within 30 days after receipt of the written request by the Privacy Officer. This deadline may be extended once for up to 30 days if the Center is unable to comply with the applicable deadline; provided, however, that the Center shall, within the original time period, notify the individual in writing of the extension, the reason therefore, and the date by which the Center will respond.
Granting the Amendment
To the extent a request for amendment is granted, the Center shall, within the period of time described in this policy:
a. make the appropriate amendment to the PHI, either by marking each occurrence of the PHI with a link to the amendment, or by correcting the PHI, such amendment becoming part of the Designated Record Set. If PHI is corrected, the time and date of the correction shall be indicated. Existing records shall not be altered in a manner that makes the original entry unreadable, except that incorrectly filed information may simply be moved to the correct Patient’s file;
b. identify each person, including Business Associates, that the Center knows to have the PHI and that may have relied, or could foreseeably rely, on such PHI to the detriment of the individual; and
c. notify the Individual in writing that the amendment has been made, of all identified persons it has identified in paragraph (b), and that the Center will make reasonable efforts to provide the amendment within a reasonable time to the identified persons.
Denying the Amendment
The Center would deny an amendment to PHI for reasons such as:
a. The PHI was not created by the Center, unless the Patient provides a reasonable basis to believe that the originator of PHI is no longer available to act on the requested amendment.
b. The PHI is not part of the designated record set.
c. The PHI would not be available for inspection.
d. The PHI is deemed to be accurate and complete.
To the extent a request for amendment is denied, the Center shall, within the period of time described in this policy:
a. notify the Patient, in writing, of such denial which shall include the following information: (i) the basis for the denial; (ii) a statement that notifies the individual of the right to submit a written statement disagreeing with the denial; (iii) a description of how to file such statement of disagreement; (iv) the right, if the individual does not submit a statement of disagreement, to request that the Center provide both the request and its denial as part of any future Disclosures of the PHI; and, (v) a description of how the Individual may complain to the Secretary of the Health and Human Services Department.
b. permit the Patient to submit a written statement disagreeing with the denial and containing the basis for such disagreement. The Center may reasonably limit the length of a statement of disagreement. After receiving a statement of disagreement from a Patient, the Center may prepare a written rebuttal, in which case the Center shall provide a copy of the written rebuttal to the individual. The Center shall include the request for amendment, the denial, any statement of disagreement, and any rebuttal in the Designated Record Set, linked to the PHI that is the subject of the denied amendment.
Receiving a Notice of Amendment from another HIPAA Covered Entity
a. If the Callier Center is informed by another Covered Entity of an amendment to an individual’s PHI that the Center maintains in a Designated Record Set and received from the Covered Entity, the Center shall make the appropriate amendment to the PHI either by: (i) marking each occurrence of the PHI with a link to the amendment; or, (ii) correcting the PHI. If PHI is corrected, the time and date of the correction shall be indicated. Existing records shall not be altered in a manner that makes the original entry unreadable, except that incorrectly filed information may simply be moved to the correct Patient’s file.
b. All such amendments become part of the Designated Record Set
c. The Center shall communicate such amendment to any Business Associate who also possesses the PHI.
Future Disclosures
a. To the extent the Center grants a Patient’s requested amendment or complies with a Covered Entity’s notice of amendment, any future Disclosure of the PHI that is subject to the amendment shall include the amendment.
b. To the extent the Center denies an individual’s requested amendment and the Patient submits a statement of disagreement, any future Disclosure of the PHI that is the subject of the denied amendment that is not a standard transaction, shall include the following documents (or a summary thereof): the requested amendment, the denial, the statement of disagreement, and the Center’s rebuttal, if any; or, in lieu of submitting a statement of disagreement, the individual requests that inclusion of the requested amendment and the denial, any future Disclosure of the PHI shall include such documents or a summary thereof: the requested amendment and the denial.
HIPAA Regulatory Citation: 45 CFR § 164.526 Effective: 04/13/2003
Revised: 05/26/2015, 04/14/2013
Reviewed: 10/21/2022, 03/24/2021, 08/13/2015
Heather Zimmerman, HIPAA Privacy Officer
UT Dallas Callier Center
