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Section IV – Administration

  1. SLM has designated either of its Owner/Members to be responsible for receiving and processing all requests for access to inspect or copy Health Records.  Responsibilities include:

a. Recording the date of receipt of requests.

b. Maintaining communication with the requesting individual to ensure the fulfillment of the request within the applicable period of time.

c. Determining and documenting the circumstances under which the request was made.

d. Routing the request for approval.

Section III – Denial of Access

  1. In the following circumstances, SLM may deny a patient access to the Health Record requested without giving the patient an opportunity for review of the denial, if the Health Record requested:
    a. was compiled for use in a civil, administrative, or criminal proceeding;
    b. is subject to the Clinical Laboratory Improvements Amendments of 1988 (42 U.S.C. 263a) or exempt from the Amendments (42 C.F.R. § 493.3(a)(2));
    c. created or obtained by SLM in the course of research, as long as the Patient agrees to the temporary denial of access when consenting to participate in research and has been informed that the right of access will be reinstated upon completion of the research.
    d. is subject to the Privacy Act (5 U.S.C. 552a);
    e. was obtained from someone other than a health care provider under a promise of confidentiality and the access requested would be reasonably likely to reveal the source of the information.
     

  2. In the following circumstances, SLM may deny a patient access to the Health Record requested, but SLM must give the patient the right to have the denial reviewed.
    a. If a licensed health care professional has determined that the access requested is reasonably likely to endanger the life or physical safety of the patient or another person.
    b. If the Health Record requested makes reference to another person, who is not a health care provider, and a licensed health care professional has determined that the Health Record requested is reasonably likely to cause substantial harm to the referred patient.
    c. The patient’s personal representative has made the request for access and a licensed health care professional has determined that providing access to the personal representative is likely to cause substantial harm to the patient or another person.
     

  3. If SLM denies access to the Health Record requested, in whole or in part, SLM will, to the extent possible, give the patient access to any other Health Record requested, after excluding the portion as to which SLM has a ground to deny access.
     

  4. If SLM denies access to the Health Record, in whole or in part, it will provide a timely, written notice of denial to the patient that is in plain language and contains:
    a. the basis for the denial;
    b. if applicable, a statement of the individual’s review rights and a description of how he or she may exercise these rights;
    c. a description of SLM complaint process, including the process for making a complaint to the Secretary of Health and Human Services and the name, telephone number; and
    d. the name, address and phone number for SLM contact responsible for receiving complaints. 
     

  5. If SLM denies access to the Health Record requested by a patient, and the patient has the right to have the decision reviewed by a licensed health professional in accordance with this Section III of this Procedure, SLM will identify a licensed health care professional to review the denial.  The health professional must not have participated in the original decision to deny access.  The reviewing health professional will determine, within a reasonable period of time, whether or not to deny the access requested based on the standards outlined in this policy.  SLM is bound to provide or deny access to the Health Record requested based on the decision of the reviewing health care professional.  SLM will provide the findings of the review and take any other action necessary to carry out the decision of the designated reviewer. 

Pertinent capitalized terms have the meanings set forth below.  Other capitalized terms have the meanings set forth in the HIPAA Rules at 45 C.F.R. Parts 160 and 164.

 

“HIPAA Privacy Rule” shall mean 45 C.F.R. Parts 160 and 164, Subparts A and E.

 

“PHI” shall mean Protected Health Information as defined in the HIPAA Privacy Rule.

 

"Health record" means any information, whether oral or recorded in any form or medium, that relates to the past, present, or future physical or mental health or condition of a patient; the provision of health care to a patient; or the past, present, or future payment for the provision of health care to a patient.

Definitions:

  1. SLM will permit a patient to request access to inspect or to obtain a copy of their Health Record that is maintained by SLM, unless an exception applies consistent with the HIPAA Privacy Rule. 

  2. SLM requires that all requests by patients to inspect or for a copy of their Health Record to be made in writing.  SLM’s Notice of Privacy Practices informs individuals of this requirement.

  3. SLM will provide a copy of or make available for inspection the Health Record within thirty (30) days of receipt of the request. If SLM denies the request, in whole or in part, it will provide the individual with a written denial, as described in Section III below.

  4. If SLM is unable to take action with regard to a request to inspect or copy the Health Record within thirty (30) days of receipt of the request, it may extend the time for such action by up to thirty (30) days, provided that SLM provides the individual with a written statement of the reasons for the delay and the date by which SLM will complete its action on the request.  SLM may have only one such extension per request.

Procedure:

Section I – Conditions of Access

Section II – Provision of Access

  1. SLM will provide the patient with access to the Health Record in the form and format requested, if such form is readily producible.  If the Health Record requested is maintained in electronic format, SLM must provide the patient with access to the Health Record in the electronic form and format requested by the individual, if such form is readily producible. If the requested format is not readily producible, the Health Record shall be produced in a readable hard copy form or other form as agreed upon by the patient and SLM.

  2. SLM may provide the patient with a summary or explanation of the Health Record requested instead of providing access to the underlying records, if the patient agrees in advance to such a summary or explanation and any related fees.

  3. SLM will arrange a convenient time and place for the patient to inspect or obtain a copy of the Health Record requested.  At the patient request, SLM will mail or email a copy of the Health Record requested to the patient.

  4. SLM may charge the patient a reasonable, cost-based fee for copying or preparing a summary.  The fee may only include the cost of copying (supplies and labor), postage, and preparing an explanation or summary of the Health Record.

Effective Date: June 4, 2021
Legal References: 45 C.F.R. §§ 160.103; 164.103; 164.503; 164.524; 164.530; Minn. Stat. §§ 144.291 – 144.298

PROVISION OF MEDICAL RECORDS POLICY

Policy:

Sound Lifestyle Medicine, PLLC, (“SLM”) will make the patient Health Record it creates or maintains for a patient as part of its operations available for inspection and copying by a patient. Under certain circumstances, SLM may deny access to Health Records in accordance with the HIPAA Privacy Rule. 

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