The Arc of Monroe County, NYSARC, Inc
REQUEST BY PERSON SERVED FOR ACCESS TO PROTECTED HEALTH INFORMATION People served by the agency have the right to inspect and obtain a copy of most information in agency records that may be used to make decisions about them or their treatment for as long as the information is maintained in our records. People served may also request that we provide a summary of the information (instead of copies) or an explanation of complicated information. Please see our Notice of Privacy Practices for a more detailed description of these rights and the process we follow once we have received a request. To request access to records, please complete and return the following request form. Name of person served: __________________________________________________________ Last First MI Address: ______________________________________________________________________ Telephone: __________________________ (day)
______________________________ (eve)
E-mail address: _________________________________ Access Requested: Please answer the following questions. You may attach a separate page if more space is needed. 1. What information would you like to access? _______________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 2. What type of access are you requesting (check all that apply)? Inspect Copy Summary Explanation If you request to inspect the information is granted, we will provide you with further information on how to schedule an appointment with our staff to inspect your records. If you are requesting a copy, summary or explanation of the information, how would you like these materials delivered to you? You may pick up these materials at our facility or request that we send them to you by regular mail or by electronic mail. Pick-up Mail If you request is being made because of an emergency, please describe the nature of the emergency and the date when you need the information, We cannot guarantee that we will meet your deadline, but we will do our best to accommodate reasonable requests. ______________________________________________________________________________ ______________________________________________________________________________
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The Arc of Monroe County, NYSARC, Inc
Fees: Copying and distribution fees: We will charge you a reasonable fee to recover the costs of copying, mailing and the supplies used to fulfill your request. Our standard fee for copying is $0.75 per page. We will not contact you before this information is prepared. Summary or explanation: We will also charge a fee to recover the costs of providing any summary or explanations you have requested. If you have requested a summary or explanation, we will contact you with an estimate of any fees before we prepare these items so that you can decide whether to continue with your request, modify your request to reduce these fees, or withdraw your request and pay no fee. By signing below, I am requesting that The Arc of Monroe County provide me with access to health information in the manner described above. I understand that I will be contacted if any fees for a summary or explanation may be charged for fulfilling this request, and that I will have an opportunity to modify or withdraw my request if I do not want to pay those fees. ______________________________________________ Printed name of person served or personal representative
________________________ Date
______________________________________________ Signature of person served or personal representative
________________________ Date
______________________________________________ Description of personal representative’s authority
________________________ Date
Please send completed form to: Privacy Officer The Arc of Monroe County 1000 Elmwood Avenue, Suite 500 Rochester, NY 14620
For Arc of Monroe County Use only: Date received: _____/_____/_____ Disposition of request: _____ Granted; _____ Denied; _____ Partially Denied Person served notified in writing of response to request on this date: _____/_____/_____ Fee charged for fulfilling request: $_______________ Name or initials of staff person fulfilling this request: ________________________________________
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The Arc of Monroe County, NYSARC, Inc
Sample letter regarding extension of time to reply to request [Date] [Name] [Address] [City, State, Zip] Re: Request for access to protected health information
Dear [ ]: This letter is in response to your request for access to your protected health information, which we received from you on [______]. We have been working to determine whether we can grant your request. We are usually able to process requests within 30 days if the records are maintained on-site in our program and within 60 days if the records are maintained off-site at another location. Your records are maintained: On-site Off-site both on-site and off-site. For the following reason(s), we need an additional 30 days to respond to your request for access to these records: We are still working to access the information you requested We are still working to prepare the information you requested We are still working to determined whether all or part of your request may be granted. We expect to have a final answer for you no later than _____________________. If additional time is required, we will notify you again. Please contact the director of this program, the privacy officer, the CEO, the COO, or the CFO if you have questions or concerns about this delay. All requests can be mailed to: The Arc of Monroe County 1000 Elmwood Ave Suite 500 Rochester, NY 14620 Thank you. Sincerely,
[sender’s name]
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The Arc of Monroe County, NYSARC, Inc
Sample letter notifying a person served of fees for access
[Date] [Name] [Address] [City, State, Zip] Re: Request for access to protected health information
Dear [ ]: This letter is in response to your request for access to your protected health information, which we received from you on [______]. We have determined that the following fees will apply if we process you request: A fee of $_______ per hour will be charged to prepare a summary of the information for you. We estimate that the preparation will take _____ hour(s). A fee of $_______ per hour will be charged to prepare an explanation of the information for you. We estimate that the preparation will take _____ hour(s). We want you to know that you have the following options: You may ask us to proceed with you request and pay the fees referred to in this letter. You may modify you request and reduce the applicable fees. You may withdraw your request and pay no fee. Please contact the director of this program, the privacy officer, the CEO, the COO, or the CFO to share your preferences and arrange for payment of any applicable fees. Our mailing address is: The Arc of Monroe County 1000 Elmwood Ave Suite 500 Rochester, NY 14620 If we do not hear from you within 60 days, we will assume that you have decided to withdraw your request. Thank you. Sincerely,
[Name of sender]
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The Arc of Monroe County, NYSARC, Inc
Recording form for access provided to a person served or their representative Name of person served: __________________________________________________________ This form must be completed by staff responsible for records when a person served or his/her personal representative is granted access to his/her protected health information. The staff responsible for records who is completing the form should remember to print his/her name where provided and sign and date the form. Receipt of access Who received access to the information:
Person served
Personal representative
If a personal representative accessed the information: The personal representative has the authority to make health care decisions on behalf of the person served Yes No The person served is 18 or older Yes No The person served was notified of the personal representatives request for access to his/her protected health information Yes No
Inspection Complete this section if the person served or his/her legal representative was permitted to inspect information. What information was the person served or his/her personal representative allowed to inspect? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ When did the person served or personal representative inspect this information? ____/____/____
Copies Complete this section if the person served or his/her personal representative was provided with copies of information. What information did the person served or his/her personal representative receive copies of? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ How were these copies provided: Check one: Pick up By mail By e-mail Mailing address: _____________________________________________________________ Email address: ______________________________________________________________
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The Arc of Monroe County, NYSARC, Inc
When were these copies provided? ____/____/____ What fee was charged to the person served or his/her personal representative for provided these copies? $_________________
Summary or explanation of information Complete this section if the person served or his/her personal representative was provided with a summary or explanation of the requested information. What is the title of the summary of explanation? ______________________________________ Has a copy of the summary or explanation been added to the person’s designated record set? Yes No Who prepared the summary or explanation? __________________________________________ What fee was charged to the person served for providing this summary or explanation? $ ______
_____________________________________________________ Printed name of staff with responsibility for records
__________________ Date
_____________________________________________________ Signature of staff with responsibility for records
__________________ Date
REMINDER: Add this form to the person’s designated record set to be filed in the section with individual rights along with copies of any summaries or explanations provided to the person served.
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The Arc of Monroe County, NYSARC, Inc
Sample letter denying access
[Date] [Name] [Address] [City, State, Zip] Re: Request for access to protected health information
Dear [
]:
This letter responds to your request to access your protected health information, which we received from you on ____________. For the reasons stated below, we are denying your request for access to all or part of this information: The request was not in writing The information requested is not available in records we use to make decisions about your treatment or benefits. However, this information may be available in records maintained by ____________________________________________________________ You have requested access to psychotherapy notes which are not available for inspection and copying by people served. We have obligations to other parties to keep the information you requested confidential. We have determined that granting your request would violate our confidentiality obligations. An authorized officer from a correctional institution has certified that granting your request to copy your information would jeopardize the health, safety, security, custody or rehabilitation of you or another person. We believe that granting your request is reasonably likely to endanger a person’s life or physical safety. The information you have requested refers to another person (who is not a health care provider), and we believe that granting your request is reasonably likely to cause substantial hard to that other person. You are the personal representative of the person served and we believe that granting your request is reasonably likely to cause substantial harm to the person served or a third person. The information you requested was prepared in anticipation of civil or criminal litigation or an administrative proceeding. This denial applies to all or part of the information you requested. We will provide you with a summary of any information we cannot permit you to access. If we are denying only part of your request, you will be given complete access to the remaining information after we have excluded the parts which we cannot permit you to access.
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The Arc of Monroe County, NYSARC, Inc
You have the right to have this decision reviewed by a licensed health care professional who was not directly involved in our initial decision to deny your request. If you want to exercise this right, please contact the director of this program, the privacy officer, the CEO, the COO, or the CFO. All requests can be mailed to: The Arc of Monroe County 1000 Elmwood Ave Suite 500 Rochester, NY 14620 They can also be submitted by phone at (585) 271-0660. We will comply with the health care professional’s decision. If the health care professional agrees with our decision, you will have the opportunity to seek further review by a special committee appointed by the State of New York. If you believe that we have improperly handled your request to access your protected health information, you may file a complaint with us or with the Secretary of the United States Department of Health and Human Services. To file a complaint with us, please contact the director of this program, the privacy officer, the CEO, the COO, or the CFO. All requests can be submitted at the address and phone number listed above. No one can retaliate against you for filing a complaint. Thank you. Sincerely,
[name of sender]
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The Arc of Monroe County, NYSARC, Inc
Sample letter following review of denial of access [Date] [Name] [Address] [City, State, Zip] Re: Request for access to protected health information Dear [
]:
This letter notifies you of the results of the review provided by a licensed health care professional who was not directly involved in our initial decision to deny your request to access your protected health information. The name of the health care professional who reviewed your request is Ms. Barbara Wale. Ms. Wale has reached the following conclusion: Your request was properly denied for the reason provided in the agency’s initial notice You request was improperly denied for the reason provided in the agency’s initial notice, but it properly denied for another reason which is, ______________________________. Your request was properly denied with respect to part of the information. The request was not properly denied for another part of the information. Please contact the administrator of the program to set up an appointment to inspect the information which you are entitled to access. If you have requested copies, we will provide them in the manner requested on your initial request form after we have removed the information we cannot permit you to access. You request was improperly denied. Please contact the administrator of your program to set up an appointment to inspect the information. If you have requested copies, we will provide them in the manner requested on your initial request form. You have the right to have this decision reviewed by a committee appointment by the State of New York. If you want to exercise this right, please contact Office of Counsel at OMRDD (518) 474-7700. If you believe that we have improperly handled your request to access your protected health information, you may file a complaint with us, with the OMRDD Clinical Record Access Review Committee, or with the secretary of the United States Department of Health and Human Services. To file a complaint with us, please contact the privacy officer at (585) 271-0660. No one can retaliate against you for filing a complaint. Thank you. Sincerely,
[name of sender]
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