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Administrative (Non-Clinical) Policy
This administrative policy applies to the operations and staff of the University of Wisconsin Hospitals and
Clinics Authority (UWHCA) as integrated effective July 1, 2015, including the legacy operations and staff
of University of Wisconsin Hospital and Clinics (UWHC) and University of Wisconsin Medical
Policy Title: Patient Right to Access (View) Their Protected Health
Effective Date: 06/01/2017
Chapter: Health Information Management
To ensure individual right of access to inspect and obtain copies of their Protected Health Information
(PHI) in compliance with state and federal statutes and regulations.
II. POLICY ELEMENTS
A. Patients, or their legally authorized representative, (“Individuals”) have the right of access to
inspect and obtain copies of their UW Health Protected Health Information in one or more
designated record sets, during or subsequent to treatment upon submission of a written request
1. Clinical, Patient Relations/Patient Resources, and Health Information Management (HIM)
staff are authorized to grant access to PHI.
B. This policy provides guidance for access to PHI only. Refer to those procedures set forth in
Administrative policies 4.10 (workers comp), 4.13 (general release), 4.30 (HIV), or 4.38
(AODA) re: release/disclosure of PHI
1. Requests for copies of the entire medical record or any requests from attorneys must be
referred to HIM.
C. Requests for access to radiology images should be directed to Enterprise Imaging.
D. UW Health has the right to deny access under certain conditions per section V.B. All denials of
access must be referred to HIM.
E. Staff must verify identity and authority of the individual requesting access to PHI. This can be
accomplished orally, or using photo ID or other documents such as guardianship papers or
POAHC papers with a statement of incapacity (if applicable).
F. To provide an Individual access to the patient's electronic medical record, the request should be
submitted to HIM to set up access whereby only that information authorized is available.
1. See Section V. for access procedures.
2. If urgent access is needed during off hours, the HIM ROI Supervisor or Assistant Director
of HIM should be contacted.
G. To provide an Individual access to the patient's paper medical record, a UW Health employee
must be present at all times to protect the integrity and confidentiality of the medical record.
1. Contents of the medical record cannot be changed, deleted or removed by the patient.
(See Administrative policy-6.14 Amendment of the Medical Record for the procedure for
a patient to request an amendment to the medical record).
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Designated Record Set means a the group of records maintained by or for the healthcare organization
that is used, in whole or in part, by or for the organization to make decisions about individuals. The
Record includes any item, collection, or grouping of information that contains protected health
information and is maintained, collected, used or disseminated by or for the organization.
“Individual” refers to the patient, or legally authorized representative.
Legally Authorized Representative is an individual who, under state law, is authorized to make
decisions about a patient. State law determines the age and ability of an individual to request access to a
patient's medical record. Any questions about the ability to access a record shall be directed to the
Director or Assistant Director of Health Information Management (HIM).
Medical Record includes records used to provide or document treatment decisions about the patient.
The "medical record" includes the paper and electronic medical record.
Protected Health Information (PHI). Individually identifiable health information that is transmitted or
maintained in any form, including oral, written, or electronic. Protected health information includes
demographic, health, and financial information.
Psychotherapy Notes means notes recorded (in any medium) by a health care provider, who is a mental
health professional, for his or her personal use in treating his/her patient and which document or analyze
the contents of conversation during a private counseling session or of a group, joint, or family
counseling session, that are separated from the rest of the individual’s medical record. Psychotherapy
notes do not include a patient’s treatment records.
A. Requesting Access (viewing of PHI): Following the procedure defined below, UW Health
must provide the Individual with access to the PHI in the requested form or format, if it is
readily producible in such form or format. If the PHI is not producible in the requested form
or format, UW Health must provide the Individual with a readable hard copy form, or other
form and format as agreed to by the Individual and UW Health (see Administrative Policy
1. General Review. Individuals may request to access and inspect their PHI, but
coordination of access should be performed through HIM during normal business hours
(See section C1 – C4 below).
a. For general requests to access the paper or electronic medical record, refer requester to
HIM at 608-263-6030, Option 3 to coordinate a viewing at 8501 Excelsior Drive during
normal business hours of Monday – Friday, 8 am to 4:15 pm.
2. Review with a Clinician or Patient Relations. UW Health can provide an individual
access to their electronic PHI for review with a clinician or Patient Relations during normal
business hours. To do this:
a. Requests for access to PHI must be in writing by the Individual and can be
accomplished using the Individual’s Request to Access PHI,, scanned and emailed to
HISReleaseMedicalinf@uwhealth.org (HIM – Release of Info in the Outlook Address
i. HIM will create a release of information report limited to the information requested.
The report will be viewable electronically within Health Link.
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ii. A letter will be faxed or emailed to the physician/clinicians, Patient Relations, or
inpatient unit that details how to access the Health Link report created for the
iii. Physician/clinician or inpatient unit will provide a computer along with
instructions for access for the patient/authorized reviewer.
3. Access to Paper Medical Record. Individuals may request to access and inspect their
paper medical record, but coordination of access should be performed through HIM during
normal business hours or as provided in section V.A.1.a.
a. All paper medical records are maintained at an off-site storage facility and 24 business
hours’ notice is needed to access the record.
4. Disclosure of PHI. Refer to Administrative Policy 4.13 Using and Disclosing (or Releasing)
Protected Health Information.
B. Denial of Access to PHI - All denials of access to PHI must be referred to HIM. UW Health
staff may deny access to PHI under the following circumstances:
1. Inaccessible Information – Individuals are not permitted to access the following
a. Psychotherapy notes-personal notes made and kept by the therapists for their purposes
b. Information compiled in anticipation of or for use in a civil, criminal, or administration
action or proceeding.
c. The PHI is exempt from CLIA (Clinical Laboratory Improvements Amendments of
1988), i.e., PHI created in research laboratories that test human specimens but do not
report patient specific results for diagnosis, treatment or health assessment of individual
2. Reviewable Denials for Access - UW Health may deny an Individual access to PHI in the
following situations, if a licensed, healthcare professional, using their professional
judgment, has determined that:
a. The access is likely to endanger the life or physical safety of the individual or another
b. The PHI makes reference to another person who is not a healthcare provider, and access
to the information requested is likely to cause substantial harm to such other person.
c. The request for access is made by the individual's legally authorized representative and
UW Health has determined that access is likely to cause substantial harm to the
individual or another person.
d. Procedure for Denial of Access. If access is denied for any of the reasons above,
UW Health will provide the individual requesting access with a written statement
indicating the reason for denial, and will include:
i. A statement of the Individual's right to have the denial reviewed
ii. A statement informing the individual that they have a right to file a complaint.
iii. The name or title, and telephone number of the contact person or office designated to
direct such complaints (Patient Relations Department at G7/210 or 608-263-8009).
e. An individual may request a review of denial:
i. UW Health will designate a healthcare professional who was not directly involved
in the denial to review the decision to deny access
ii. The designated reviewer will determine, within 30 business days, whether or not
to deny the access requested
iii. UW Health will provide a written notice of the determination of the designated
reviewer, written in plain language and contain:
- The basis for the denial
- A statement of the patient’s review rights, if any, including a description of
how the patient may exercise such review rights; and
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- A description of how the patient may complain to UW Health or to the
Secretary of the U.S. Department of Health and Human Services. The
description must include the name, or title, and telephone number of the
UW Health Privacy Officer.
3. Unreviewable Denials - UW Health may deny a request to access PHI without review in
the following circumstances:
a. An inmate's request to copy his or her records if providing a copy of the information
would jeopardize the health, safety, security, custody, or rehabilitation of the individual
or another inmate, or the safety of an officer (see Administrative Policy 4.13)
b. Information created or obtained in the course of research that includes treatment may
be temporarily suspended until the completion of the research if:
i. The Individual agreed to the denial of access when consenting to participate in the
ii. UW Health informs the Individual that he/she has a right to access the
information upon completion of the research
c. The information that is subject to the Privacy Act, 5 U.S.C. 552a, may be denied, if the
denial of access under the Privacy Act would meet the requirements of the law.
d. If the PHI were obtained from someone other than the health care provider under the
promise of confidentiality and access would likely reveal the source of the information.
4. Documentation of Denial to Access of PHI
a. All denials to access to PHI will be documented by HIM staff on the "Denial of Access
to Protected Health Information" form.
b. Completed Denial form will be scanned into the medical record.
C. Approval of Request to Access of Medical Records
1. UW Health must provide the Individual with access to the PHI in the requested form
or format, if it is readily producible in such form or format. If the PHI is not
producible in the requested form or format, UW Health must provide the Individual
with a readable hard copy form, or other form and format as agreed to by the
Individual and UW Health.
2. Viewing of the UW Health medical record in HIM must be scheduled with Health
Information Management during normal business hours of 8 am to 4:00 pm, Monday
through Friday (excluding holidays) at 608-263-6030, Option 3, or by coming to HIM at
8501 Excelsior Drive. Appointments for viewing will be made with a minimum of 24
3. Clinical staff or Patient Relations staff will arrange a time that allows an Individual
access to their PHI, if performed at either of those sites.
4. UW Health will schedule appointment within 30 days of request unless request is denied (see
Denial of Request above).
a. If UW Health is unable to schedule viewing appointment within 30 days of receipt of
request, one additional 30-day extension may be taken.
i. Notification of this extension will be made in writing to the requester.
b. Viewing of an Individuals PHI will be performed within HIM and will be done under
the supervision of the HIM staff.
c. See Administrative Policy 4.13 re: Using and Disclosing (or Releasing) Protected
Health Information for the detailed procedure for release of information.
1. Individual’s Request for Access to Protected Health Information.
2. Notice of Denial of Access to Protected Health Information.
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1. 45 CFR §164.501
2. Individuals' Right under HIPAA to Access their Health Information 45 CFR §164.524
3. 45 CFR §164.524(a)(1)
4. 45 C.F.R §164.51
5. 42 §U.S.C 263a
6. 42 §C.F.R 493.3(a)(2)
7. Wisc. Stat. 51.61(1)(n)
8. Wisc. Stat. 146.83
Senior Management Sponsor: VP, CIO
Author: Director, Health Information Management
Reviewers: Medical Records Committee
Approval Committee: UW Health Administrative Policy and Procedure Committee
UW Health Chief Administrative Officer
Previous revision: 09/01/2014
Next revision: 06/01/2020