• Blog
  • Services
    • PHIshMD Ongoing Training
    • HIPAA Compliance
    • Discover Vulnerabilities to Patient PHI
  • Store
    • HIPAA Secure Now Service Store
  • Contact Us
    • Sales Inquiry
    • Customer Support
  • Resources
    • Free Healthcare Security Check Up Quiz
    • HIPAA Compliance Requirements | A Guide
    • Webinars & Downloadable Content
    • Use our free Breach Cost Calculator
    • HIPAA Secured Seal
    • In-Email Training & Analysis | Catch Phish

Call us at: 877-275-4545

Client or Partner? Login here
HIPAA Secure Now!HIPAA Secure Now!
  • Blog
  • Services
    • PHIshMD Ongoing Training
    • HIPAA Compliance
    • Discover Vulnerabilities to Patient PHI
  • Store
    • HIPAA Secure Now Service Store
  • Contact Us
    • Sales Inquiry
    • Customer Support
  • Resources
    • Free Healthcare Security Check Up Quiz
    • HIPAA Compliance Requirements | A Guide
    • Webinars & Downloadable Content
    • Use our free Breach Cost Calculator
    • HIPAA Secured Seal
    • In-Email Training & Analysis | Catch Phish

HHS offers guidance regarding HIPAA and individual access

January 11, 2016 Posted by Art Gross HIPAA, Policies and Procedures No Comments

The Department of Health and Human Services (HHS) has issued guidance regarding an Individual’s Right under HIPAA to Access their Health Information.

The link should be bookmarked by all organizations as a reference for future guidance, questions and answers:

http://www.hhs.gov/hipaa/for-professionals/privacy/guidance/access/index.html

Here is the introduction text from the guidance:

Providing individuals with easy access to their health information empowers them to be more in control of decisions regarding their health and well-being. For example, individuals with access to their health information are better able to monitor chronic conditions, adhere to treatment plans, find and fix errors in their health records, track progress in wellness or disease management programs, and directly contribute their information to research. With the increasing use of and continued advances in health information technology, individuals have ever expanding and innovative opportunities to access their health information electronically, more quickly and easily, in real time and on demand. Putting individuals “in the driver’s seat” with respect to their health also is a key component of health reform and the movement to a more patient-centered health care system.

The guidance is pretty thorough and long and should be read in detail. Here are some highlights:

 

General Right

Individuals have a right to access this PHI for as long as the information is maintained by a covered entity, or by a business associate on behalf of a covered entity, regardless of the date the information was created; whether the information is maintained in paper or electronic systems onsite, remotely, or is archived; or where the PHI originated (e.g., whether the covered entity, another provider, the patient, etc.).

Information Included in the Right of Access: The “Designated Record Set”

Individuals have a right to access PHI in a “designated record set.” A “designated record set” is defined at 45 CFR 164.501 as a group of records maintained by or for a covered entity that comprises the:

  • Medical records and billing records about individuals maintained by or for a covered health care provider;
  • Enrollment, payment, claims adjudication, and case or medical management record systems maintained by or for a health plan; or
  • Other records that are used, in whole or in part, by or for the covered entity to make decisions about individuals. This last category includes records that are used to make decisions about any individuals, whether or not the records have been used to make a decision about the particular individual requesting access.

 

Information Excluded from the Right of Access

An individual does not have a right to access PHI that is not part of a designated record set because the information is not used to make decisions about individuals. This may include certain quality assessment or improvement records, patient safety activity records, or business planning, development, and management records that are used for business decisions more generally rather than to make decisions about individuals.

In addition, two categories of information are expressly excluded from the right of access:

  • Psychotherapy notes, which are the personal notes of a mental health care provider documenting or analyzing the contents of a counseling session, that are maintained separate from the rest of the patient’s medical record. See 45 CFR 164.524(a)(1)(i) and 164.501.
  • Information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding. See 45 CFR 164.524(a)(1)(ii).

Personal Representatives

An individual’s personal representative (generally, a person with authority under State law to make health care decisions for the individual) also has the right to access PHI about the individual in a designated record set (as well as to direct the covered entity to transmit a copy of the PHI to a designated person or entity of the individual’s choice), upon request, consistent with the scope of such representation and the requirements discussed below.

 

Requests for Access

Requiring a Written Request

A covered entity may require individuals to request access in writing, provided the covered entity informs individuals of this requirement. See 45 CFR 164.524(b)(1). Covered entities also may offer individuals the option of using electronic means (e.g., e-mail, secure web portal) to make requests for access. In addition, a covered entity may require individuals to use the entity’s own supplied form, provided use of the form does not create a barrier to or unreasonably delay the individual from obtaining access to his PHI, as described below.

Verification

The Privacy Rule requires a covered entity to take reasonable steps to verify the identity of an individual making a request for access. See 45 CFR 164.514(h). The Rule does not mandate any particular form of verification (such as obtaining a copy of a driver’s license), but rather generally leaves the type and manner of the verification to the discretion and professional judgment of the covered entity, provided the verification processes and measures do not create barriers to or unreasonably delay the individual from obtaining access to her PHI

Unreasonable Measures

While the Privacy Rule allows covered entities to require that individuals request access in writing and requires verification of the identity of the person requesting access, a covered entity may not impose unreasonable measures on an individual requesting access that serve as barriers to or unreasonably delay the individual from obtaining access.

 

Providing Access

Form and Format and Manner of Access

The Privacy Rule requires a covered entity to provide the individual with access to the PHI in the form and format requested, if readily producible in that form and format, or if not, in a readable hard copy form or other form and format as agreed to by the covered entity and individual.

  • Requests for Paper Copies – Where an individual requests a paper copy of PHI maintained by the covered entity either electronically or on paper, it is expected that the covered entity will be able to provide the individual with the paper copy requested.
  • Requests for Electronic Copies –
    Where an individual requests an electronic copy of PHI that a covered entity maintains only on paper, the covered entity is required to provide the individual with an electronic copy if it is readily producible electronically (e.g., the covered entity can readily scan the paper record into an electronic format) and in the electronic format requested if readily producible in that format, or if not, in a readable alternative electronic format or hard copy format as agreed to by the covered entity and the individual.
  • Where an individual requests an electronic copy of PHI that a covered entity maintains electronically, the covered entity must provide the individual with access to the information in the requested electronic form and format, if it is readily producible in that form and format.

Timeliness in Providing Access

In providing access to the individual, a covered entity must provide access to the PHI requested, in whole, or in part (if certain access may be denied as explained below), no later than 30 calendar days from receiving the individual’s request.

Fees for Copies

The Privacy Rule permits a covered entity to impose a reasonable, cost-based fee if the individual requests a copy of the PHI (or agrees to receive a summary or explanation of the information). The fee may include only the cost of: (1) labor for copying the PHI requested by the individual, whether in paper or electronic form; (2) supplies for creating the paper copy or electronic media (e.g., CD or USB drive) if the individual requests that the electronic copy be provided on portable media; (3) postage, when the individual requests that the copy, or the summary or explanation, be mailed; and (4) preparation of an explanation or summary of the PHI, if agreed to by the individual.

 

Denial of Access

Grounds for Denial

Under certain limited circumstances, a covered entity may deny an individual’s request for access to all or a portion of the PHI requested. In some of these circumstances, an individual has a right to have the denial reviewed by a licensed health care professional designated by the covered entity who did not participate in the original decision to deny.

Note: there are Unreviewable and Reviewable grounds for denial. Examples of both are given in the guidance. The process for denying a request is detailed as well.

 

Individual’s Right to Direct the PHI to Another Person

An individual also has a right to direct the covered entity to transmit the PHI about the individual directly to another person or entity designated by the individual. The individual’s request to direct the PHI to another person must be in writing, signed by the individual, and clearly identify the designated person and where to send the PHI. A covered entity may accept an electronic copy of a signed request (e.g., PDF), as well as an electronically executed request (e.g., via a secure web portal) that includes an electronic signature.

 

State Laws

State laws that provide individuals with greater rights of access to their PHI than the Privacy Rule, or that are not contrary to the Privacy Rule, are not preempted by HIPAA and thus still apply. For example, a covered entity subject to a State law that requires that access to PHI be provided to an individual in a shorter time frame than that required in the Privacy Rule must provide such access within the shorter time frame because the State law is not contrary to the Privacy Rule.

 

FAQ

The guidance provides frequently asked questions and answers. The questions provide more insight into the regulations. There are around 15 questions / answers and examples include:

  • Under what circumstances may a covered entity deny an individual’s request for access to the individual’s PHI?
  • How timely must a covered entity be in responding to individuals’ requests for access to their PHI?
  • Under the HIPAA Privacy Rule, do individuals have the right to an electronic copy of their PHI?

HHS has provided much needed insight into an individual’s right to access their own information. We are asked these questions all the time and this topic causes confusion in many healthcare organizations.

Tags: Policies and Procedures
No Comments
Share
0

You also might be interested in

Introducing HIPAA Secure Now!

Feb 13, 2011

We are proud to announce the launch of the HIPAA[...]

Using patient record security as a competitive advantage

Using patient record security as a competitive advantage

Mar 7, 2011

The following blog was written a year ago but the[...]

Analysis of OCR’s message on HIPAA

Analysis of OCR’s message on HIPAA

Mar 16, 2011

OCR is serious about enforcement! That is a message that[...]

Leave a Reply Cancel Reply

Recent Posts

  • One Click, $600K Lost: The HIPAA Lesson You Can’t Ignore
  • HIPAA Enforcement: What Every Healthcare Practice Needs to Know
  • Simplifying HIPAA for Small Practices
  • Staying Ahead of AI-Driven Cyber Threats: How HIPAA’s 2025 Security Rule Updates Help
  • AI in Healthcare: Opportunity or Risk? The Answer is Both

Recent Comments

  • Why Your Practice Needs an AI Acceptable Use Policy - HIPAA Secure Now! on How Gen AI is Transforming Everyday Healthcare
  • HIPAA Security Rule Changes 2025: What Your Healthcare Practice Must Know Now - The HJN Blog on 2025 HIPAA Security Rule Updates
  • Too Small for an OCR Audit? 2025 Proves Otherwise - HIPAA Secure Now! on How Engaging Training Reduces Employee Errors in Healthcare
  • 2025 HIPAA Security Rule Updates - HIPAA Secure Now! on How Engaging Training Reduces Employee Errors in Healthcare
  • Overcoming HIPAA Compliance Challenges for Small Healthcare Practices - HIPAA Secure Now! on How Engaging Training Reduces Employee Errors in Healthcare

Archives

  • May 2025
  • April 2025
  • March 2025
  • February 2025
  • January 2025
  • December 2024
  • November 2024
  • October 2024
  • September 2024
  • August 2024
  • July 2024
  • June 2024
  • May 2024
  • April 2024
  • March 2024
  • February 2024
  • January 2024
  • December 2023
  • November 2023
  • October 2023
  • September 2023
  • August 2023
  • July 2023
  • June 2023
  • May 2023
  • April 2023
  • March 2023
  • February 2023
  • January 2023
  • December 2022
  • November 2022
  • October 2022
  • September 2022
  • August 2022
  • July 2022
  • June 2022
  • May 2022
  • April 2022
  • March 2022
  • February 2022
  • January 2022
  • December 2021
  • November 2021
  • October 2021
  • September 2021
  • August 2021
  • July 2021
  • June 2021
  • May 2021
  • April 2021
  • March 2021
  • February 2021
  • January 2021
  • December 2020
  • November 2020
  • October 2020
  • September 2020
  • August 2020
  • July 2020
  • June 2020
  • May 2020
  • April 2020
  • March 2020
  • February 2020
  • January 2020
  • December 2019
  • November 2019
  • October 2019
  • September 2019
  • August 2019
  • July 2019
  • June 2019
  • May 2019
  • April 2019
  • March 2019
  • February 2019
  • January 2019
  • November 2018
  • October 2018
  • September 2018
  • August 2018
  • July 2018
  • June 2018
  • May 2018
  • April 2018
  • March 2018
  • February 2018
  • January 2018
  • December 2017
  • November 2017
  • October 2017
  • September 2017
  • August 2017
  • July 2017
  • June 2017
  • May 2017
  • April 2017
  • March 2017
  • February 2017
  • January 2017
  • December 2016
  • November 2016
  • October 2016
  • September 2016
  • August 2016
  • July 2016
  • June 2016
  • May 2016
  • April 2016
  • March 2016
  • February 2016
  • January 2016
  • December 2015
  • November 2015
  • October 2015
  • September 2015
  • August 2015
  • June 2015
  • May 2015
  • April 2015
  • March 2015
  • February 2015
  • January 2015
  • December 2014
  • November 2014
  • October 2014
  • September 2014
  • August 2014
  • July 2014
  • June 2014
  • May 2014
  • April 2014
  • March 2014
  • February 2014
  • January 2014
  • December 2013
  • November 2013
  • October 2013
  • September 2013
  • August 2013
  • July 2013
  • June 2013
  • May 2013
  • April 2013
  • March 2013
  • February 2013
  • January 2013
  • December 2012
  • November 2012
  • October 2012
  • September 2012
  • July 2012
  • June 2012
  • May 2012
  • April 2012
  • March 2012
  • February 2012
  • January 2012
  • December 2011
  • November 2011
  • October 2011
  • September 2011
  • August 2011
  • July 2011
  • June 2011
  • May 2011
  • April 2011
  • March 2011
  • February 2011

Categories

  • Backup & Disaster Recovery
  • Business Associates
  • Client News
  • Download
  • Healthcare Industry
  • HIPAA
  • HIPAA Audits
  • HIPAA Violations
  • HSN News
  • Legal
  • MACRA
  • Policies and Procedures
  • Press Release
  • Remote Workforce
  • Risk Assessment
  • Scams
  • Security
  • Security Reminders
  • Security Training
  • Telehealth
  • Uncategorized
  • Webinar
  • Website

Meta

  • Log in
  • Entries feed
  • Comments feed
  • WordPress.org

Contact Us

  • HIPAA Secure Now
  • 55 Madison Ave, Suite 400 Morristown, NJ 07960
  • (877) 275 - 4545
  • info@hipaasecurenow.com

Find us on Social Media

LEGAL

Privacy Policy

Terms of Service

Subscribe to our Newsletter

  • Hidden

© 2025 · HIPAA Secure Now!

Prev Next