+9 ?13. "Au-"d ,tumczr DEPARTMENT OF HEALTH HUMAN SERVICES OFFICE OF THE SECRETARY a Voice- (404] 562??336. [300) 368-1019 Of?ce for Civil Rights, Region IV TDD (404} 562-?884. {son} sat?res? 61 so";th Street, 3. w. (FAX) {404) 5523831 Atlanta Federal Center, Suite 3370 hits-9WD?! Atlanta, GA 30303?3909 June 27, 201 . Re: {Wiwa vs. Bay Pines VA Healthcare System OCR Reference Number: 11?127468 Dear {bit?ltbitiltcl Thank you for your complaint, which was received by the U.S. Department of Health and Human Services (HHS), Of?ce for Civil Rights (OCR), on May 4, 201 In your complaint, you allege a violation of the Federal Standards for Privacy of Individually Identi?able Health Information (45 C.F.R. Parts 160 and 164, Subparts A and E, the Privacy Rule). Speci?cally, you allege that BayPines VA Healthcare System (hereinafter, ?Bay Pines?) has not accurately maintained your medical records, which is supported by your assertion that a physician with Bay Pines failed to accurately notate your medical records after undergoing an examination in October of 201 U, and your assertion that you have undergone two (2) tests, i.e. Pulmonary Function Tests, that have not been documented andfor made a part of your designated record set. OCR enforces the Privacy and Security Rules, and also enforces Federal civil rights laws which prohibit discrimination in the delivery of health and human services because of race, color, national origin, disability, age, and under certain circumstances, sex and religion. OCR will not be able to accept your complaint for investigation based on your allegations. However, your allegations could potentially reflect violations of the Privacy Rule if you had made a request for an amendment, and Bay Pines denied your request without following the processes established by the HIPAA Privacy Rule. Please note that you have a right to request an amendment. Speci?cally, the Privacy Rule states that an individual has the right to have a covered entity amend protected health information or a record about the individual in a. designated record set, i.e. medical records, for as long as the PHI is maintained in the medical records. See 45 C.F.R. Although a covered entity may deny an individual?s request for an amendment, the denial must be based on a permitted basis under the Rule, and the covered entity must provide the denial in writing and follow further requirements for denying, in whole or in part, an individual?s request for an amendment. See 45 C. .13. J64.526(a) (2), See also, 45 GER. and Under 45 C.F.R. the covered entity, i.e. Bay Pines, must permit you, as the individual, to request that the covered entity amend the PHI maintained in your medical records. Please note that under this section, it is permissible for the covered entity to require individuals to make requests for amendment in writing and to provide a reason to support a requested amendment, provided that it informs individuals in advance of such requirements. Therefore, OCR recommends that you review the covered entity?s Notice of Privacy Practices to determine if the covered entity requires individuals to make amendment requests in writing. In the alternative, you could contact Bay Pines and speci?cally request information about its process on handling amendment requests and if it requires individuals to make amendment requests in writing. OCR also recommends that you submit a request for amendment, and you could attach this letter. If the covered entity fails to permit you to make a request for an amendment, or if it fails to adhere to the requirements of the Privacy Rule in handling your amendment request, please feel ?ee to ?le a complaint with OCR. At this time, OCR is unable to assist you until you have attempted to exercise your right under the Privacy Rule to request an amendment, and we are closing your complaint. determination as stated in this letter applies only to the allegations in this complaint that were reviewed by OCR. OCR only reviewed the evidence of records pertinent to resolving the issues raised by you in the aforementioned complaint. Under the Freedom of Information Act, we may be required to release this letter or other information about this case upon request by the public. In the event OCR receives such a request, we will make every effort, as permitted by law, to protect information that identi?es individuals or that, if released, could constitute a clearly unwanted invasion of personal privacy. If you have any questions regarding this matter, please contact Sonya Hana?, Investigator, at (404) 562?7187 (Voice), (404) 562-7384 (TDD). Thank you for bringing this matter to our attention. Sincerely, Roosevelt Freeman Regional Manager