Policy/Procedure: Request To Access Personal Health Information (By Patient)
Issued by: Corporate Privacy Committee
Approved By: Board of Trustees
Date Issued: November 1, 2004
Approved On: February 24, 2005
Scope: ROHCG
Last Revised:
Reference: PHIPA, 2004. Section 52(1)
- Policy – Access Request
- Exempted and Non Applicable Information
- Request for Access Process
- Response
- Time Frame
- Approval Process
- Request for Access Granted
- Request for Access Refused
- Expedited Access
- Applicable Fees
1. Right of Access: Patients have a right to access their personal health information in the custody or under the control of the hospital, unless the information is exempted or non applicable.
2. Exempted Information: means information that is:
- Subject to legal privilege that restricts disclosure.
- Another Act prohibits the disclosure.
- The information was collected or created or used in a proceeding not yet concluded.
- The information was collected or created in the course of an inspection, investigation or similar procedure authorized by law and the proceeding appeals and processes resulting from them have not been concluded.
- Granting access could reasonably be expected to result in:
- Serious harm to the treatment or recovery of the patient or
- Serious bodily harm to another person.
- Lead to the identification of a person who was required by law to provide information to the hospital or to who provided information explicitly or implicitly in confidence and the hospital considers it appropriate to keep the name of the person confidential.
- The custodian is an institution within the Freedom of Information and Protection of Privacy Act or the Municipal Freedom of Information and Protection of Privacy Act.
Non Applicable Information: The right of access by a patient to a record of personal health information does not apply to a record of:
- Quality of care information.
- Raw data from standardized psychological tests or assessments.
- Personal health information collected or created for complying with a quality assurance program within the Health Professions Procedure Code.
3. Request for Access Process:
- Patients wanting access to personal health information should direct their requests to the Corporate Privacy Officer who can assist patients in formulating the request with the information required to locate the record. The request is made in writing, but may be oral in certain limited circumstances. The request for access is then forwarded by the Corporate Privacy Officer to Health Records.
4. Response: Health Records is required to:
- Ensure and verify both the identity, as well as, the legal authority of the patient requesting access.
5. Time Frame: Health Records is required to:
- Document the date of the request.
- Respond to the request within 30 days from the date of receipt of the request, or to a maximum of 60 days from the date of the receipt, if an extension is required.
- Provide the patient with a written notice if extending the time frame, setting out the length and the reasons for the extension or;
- Be deemed non-compliant or to have refused the request if Health Records does not respond within the time limit or before the extension expires.
6. Approval Process: Health Records is required to:
- Screen the personal health information to ensure that it does not follow under exempted or non applicable information.
- Consult a member of the College of Physicians and Surgeons or a member of the College of Psychologists of Ontario if it’s reasonable to suspect that the “harm” provisions may be a factor.
- Assess whether the request is frivolous, vexatious or made in bad faith.
7. Request Granted: Health Records is required to:
- Contact and inform the patient that the request for access has been approved.
- Set up an appointment date, time and place.
- Document the date of the viewing in the record.
- Make the record available to the patient and supervise or monitor the viewing
- Provide the patient with an explanation of abbreviations or codes used.
- Notify the patient of any applicable fees and payment schedule if the patient wishes copies of his/her record.
- Send copies to the patient upon receipt of payment.
- Document the date copes sent to the patient.
8. Request Refused: Health Records is required to:
- Notify the patient in writing that the request for access has been denied and the reasons for the refusal.
- Inform the patient that he/she is entitled to make a complaint about the refusal to the “Commissioner”.
9. Expedited Access: Health Records is required to:
- Respond to a request within a time frame that the patient specifies if the patient provides evidence that the information is required on an urgent basis, and Health Records is reasonably able to comply with the request within the specified time frame.
- Notify the patient if the urgent request is subject to any additional fees.
10. Applicable Fees: Health Records may:
- Charge the patient a reasonable administrative fee, plus copying charges for any copies the custodian provides to the patient according to the ROHCG Fee schedule.
- Provide up to ten discretionary copies of documentation to the patient without charge if the fee and copying charges would cause undue hardship to the patient.
- Charge additional fees for expedited or urgent requests.
- Apply additional fees if the records are off-site, or on microfilm based on cost recovery.
Version: January 2005