LOS ANGELES COUNTY
DEPARTMENT OF MENTAL HEALTH
  POLICY 501.01 Client's Right to Access Protected Health Information and Confidential Data
 
  PROCEDURES
  1. Upon receipt of the request, DMH provider or manager staff shall be responsible for establishing the identity of the requestor by following the procedures outlined in DMH Policy 500.06.
     
    1. Difficulty in establishing identity shall not intentionally be used to delay or hinder authorized access.
       
    2. If the signed Request for Access to Health Information (MH 603) form is submitted in person, DMH shall provide a signed copy to the requestor.
       
  2. DMH provider or manager staff shall be responsible for reviewing the record for completeness and making the decision to:
     
    1. Grant the request - DMH shall:
       
      1. Provide the client notification of the acceptance by using the Letter Responding to Client's Request for Access to Health Information (MH 604).
         
        1. Inspection shall be honored within five (5) working days.
        2. Mailed copies of the medical record shall be within 15 days.
           
      2. Provide the client with details on how to access the requested PHI and confidential data.
         
      3. Arrange with the client/representative:
         
        1. A time during business hours and a place to inspect or obtain a copy of the client's mental health record.
        2. The client or personal representative is allowed to have one other individual accompany him/her during the inspection of mental health records.
        3. If requested, provide a copy through the mail or fax.
           
      4. Produce the PHI and confidential data once, when the medical record is in more than one location.
         
      5. Shall provide a written summary or explanation if the client agrees.
         
    2. Exclude some PHI and confidential data and provide access to other PHI and confidential data requested:
       
      1. If DMH denies access to part of the PHI and confidential data, DMH shall give the client access to any other PHI and confidential data requested after excluding the PHI and confidential data to which it denied access.
         
      2. All information denied will be substituted by a summary.
         
    3. Deny access
       
      1. Under the following circumstances:
         
        1. The health care provider has determined in the exercise of professional judgment:
           
          • The access is likely to endanger the life or physical safety of the client; or,
          • The PHI and confidential data which makes reference to another person (not including treatment provider) and the access requested is reasonably likely to cause harm to the person referenced; or,
          • The request for access is made by the personal representative and that access is likely to cause substantial harm to the client or another person.
             
        2. The PHI makes reference to HIV/AIDS and/or substance abuse.
        3. Under the direction of a correctional institution, the inmate's request to obtain a copy of the PHI and confidential data would jeopardize:
           
          • The health, safety, security, custody, or rehabilitation of the client or other inmates.
          • The safety of any officer, employee, or other person at the correctional institution or those responsible for transporting the inmate.
             
        4. The client agreed to the temporary denial of access when consenting to participate in research that includes treatment and the research is not yet complete; or
        5. The PHI and confidential data were obtained from someone other than a health care provider under a promise of confidentiality and access would likely reveal the source of the information.
           
      2. The treatment provider shall inform the client in writing of the denial of access using the Letter Responding to Client's Request for Access to Health Information and the Request for Review of Denial of Access (MH 605) form.
        1. The Letter Responding to Client's Request for Access to Health Information must contain:
           
          • The basis for the denial;
          • A statement of the client's review rights including a description of how the client may exercise such review rights; and
          • A description of how the client may complain to DMH or to the United States Department of Health and Human Services.
             
        2. The Request for Review of Denial of Access form must be completed by the client if they are requesting a review.
           
          • Upon receipt, a licensed health care professional designated by DMH, who was not directly involved in the decision to deny access, shall review the case.
          • Within five (5) working days, the licensed health care professional shall determine whether or not to deny the request access and notify:
             
            1. The DMH manager involved in the denial of access
            2. Patients' Rights, and
            3. The designated representative of the DMH Privacy Officer of the final decision.
               
          • The DMH Privacy Officer or his/her designee shall provide written notice within two (2) additional working days to the client/representative of the findings of the review, using the Letter Responding to Client's Request for Review of Denial of Health Information (MH 606).
          • A copy of the final review letter shall be sent to the County's Chief Privacy Officer and recorded in the client's mental health record along with a copy of the client's Request for Review of Denial of Access form.
             
        3. If the client requests a review of a denial, where the grounds for denial are not subject to review, no further action by the treatment team is required.
           
  3. All requests, decisions, or information relating to client/representative access to mental health records, shall become part of the clinical record, including the Letter Responding to Client's Request for Access to Health Information.