HIPAA Policy Section 7.4: Right to Receive an Accounting of Disclosures

System shall recognize an Individual’s right to receive an accounting from any office within the Health Care Component of certain Disclosures of the Individual’s PHI made by or for System

7.4(1) Individual’s Right to Request an Accounting

1. System shall recognize an Individual’s right to receive an accounting of certain Disclosures of the individual’s PHI made by or for System. Such requests must be in writing and include the range of dates to which the request. If an Individual either orally notifies System of his desire to obtain an accounting or does not include a range of dates in his written request, the Privacy Officer shall give the Individual a copy of the form Request for Accounting of Disclosures in the Appendix to this Manual, in order to assist the individual with making a written, complete request.
2. The Privacy Officer shall be responsible for receiving and processing an individual’s request for an accounting and have ultimate authority regarding the content of accountings.

7.4(2) Verification of Requestor’s Identity.

1. Before an accounting is released, System shall verify the requesting person’s identity in accordance with Section 4.10 of this Manual.
2. In accordance with Section 4.12 of this Manual, an Individual’s Personal Representative shall have the right to request and receive an accounting to the same extent the Individual has such right under this Section.

7.4(3) Acting on an Individual’s Request for an Accounting.

1. As soon as practicable after receiving a written, complete request for an accounting, System shall inform all Business Associates of the request, as necessary to help it to compile the accounting or to compile its own accounting on behalf of System. In addition, prior to providing an accounting, System shall inform the Individual of any fee associated with the request imposed in  accordance with subsection 7.4(7) of this Section and allow the Individual to withdraw or modify the request for an accounting in order to avoid or reduce the fee. System shall also inform the Individual if a separate accounting is to be provided by a Business Associate.
2. System shall provide the written accounting of PHI Disclosures to the Individual within 60 days after receipt of the individual’s written, complete request for the accounting. This deadline may be extended once for up to 30 days if System is unable to comply with the applicable deadline; provided, however, System shall, within the original time period, notify the Individual in writing of the extension, the reason for the delay, and the date by which System will respond.

7.4(4) Disclosures Included in an Accounting

The accounting shall identify each Disclosure, and only such Disclosure, that satisfies all the following:

1. the Disclosure is required to be documented when made in accordance with the chart set forth in of Section 4.14 of this Manual, except that a Disclosure shall be excluded from an accounting to the extent required by this section;
2. the Disclosure was made by System or a Business Associate; and
3. the Disclosure was made (i) during the time period requested by the individual, and (ii) within six years prior to the date of the individual’s request.

7.4(5) Disclosure Descriptions Included in an Accounting

For each Disclosure listed in the accounting, the following information shall be included, except as set forth in subsection 7.4(6) of this Section:

1. the date of the Disclosure (in the case of multiple Disclosures of PHI to the same person or entity for a single purpose, the accounting need not include every date of Disclosure as long as it contains (i) the dates of the first and last Disclosure during the accounting period and (ii) the frequency, periodicity, or number of Disclosures made during the accounting period);
2. the name of the person or entity who received the PHI and, if known, such person’s address;
3. a brief description of the PHI Disclosed; and
4. either (i) a brief statement of the purpose of the Disclosure, which reasonably informs the individual of the basis for the Disclosure, or (ii) if applicable, a copy of the written request for the Disclosure.

7.4(6) Accounting for Disclosures to a Health Oversight Agency or Law Enforcement Official

If a Health Oversight Agency or law enforcement official states that including a Disclosure to the respective agency or official in an Individual’s accounting would be reasonably likely to impede the respective agency’s or official’s activities, System shall exclude such Disclosure from any accounting requested by the Individual until:

1. if such statement is made in writing and includes a time period for exclusion from the accounting, the end of such time period; or
2. in the absence of such a statement, 30 days after the receipt of the request.

7.4(7) Imposition of a Fee for an Accounting.

The first accounting requested by an Individual shall be provided free of charge. From then on, System may charge the individual a reasonable, cost-based fee for each accounting provided, but only if the accounting is requested less than 12 months after a prior request by the Individual for which System provided an accounting without charging any fee.

7.4(8) Document Retention.

For each request for an accounting, System shall retain the written request, a notice of deadline extension (if any), and the written accounting. System shall document whether a fee was imposed. System shall document any statement, including the identity of the applicable agency or official, of an accounting made in accordance with subsection 7.4(6) of this Section. All documentation shall be retained in accordance with Section 9.2 of this Manual.

REFERENCES/CITATIONS

45 C.F.R. §§ 164.504(e)(2)(ii)(G), 164.504(f)(2)(ii)(G), 164.528

65 Fed. Reg. at 82,559-61, 82,672, 82,739-44 (Dec. 28, 2000); 67 Fed. Reg. at 53,243-47 (Aug. 14, 2002)