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Management of Written Agreements

Privacy Resource Material

Letters and Forms

January 2013

 

                                  
 
 
 
 

    Privacy and Security Resources

    for Saskatchewan EMR Physicians  
     
     

    Templates – Forms and Letters  
     

    January 2013 
     
     
     
     

    Disclaimer

    The information provided in this sample templates – forms and letters section does not constitute legal advice. It is general information intended to assist physicians in understanding their obligations and general duties under The Health Information Protection Act of Saskatchewan.  The information is provided as guidance for medical practices in Saskatchewan developing privacy and security policies and procedures.

     

     

    Table of Contents 
     
     

     

     

    Access to Personal Health Information Form

    Purpose:  This form can be used when patients or their authorized representative want access to the patient��s record.  If a physician wants all requests to be on this or another form the requirement must be included in the written policy on Patient Access.  A physician may accept requests for access made verbally or in any other written format.  

    The information on this form will be used to respond to your request for your own personal health information or the personal health information of someone whom you are legally entitled to represent.  

    Name of Patient 
    Last Name    First Name 

    Other names the information may be under, e.g. maiden name 

    This information will be used in confirming the correct record

    Health Service Number: _______________ Date of birth (dd/mm/yy): _______________

    Name of Physician _________________________

     

    Contact Information

    Street address: _____________________________________

    City /town: ______________________________ Prov.______

    Postal code: ___________________

    Tel: (home) _____________________ (mobile) _________________

     

    This request is being made by an Authorized Representative/Third Party

    Last Name    First Name

    Street address: _____________________________________

    City /town: ______________________________ Prov.______

    Postal code: ___________________

    Tel: (home) _____________________ (bus) _________________

    The person requesting the personal health information is authorized under HIPA or has authority to access this information under _____________ (name of legislative or court authority).  Attach signed consent or other legal authorization for the applicant to be a designate. 

     

    Details of Request 

    1. Please describe, in as much detail as possible, the information you are requesting.
    1. Indicate if you also want  
       
       
       
       
      • access to information about the disclosure of your information,
      • audit of your personal health information in the EMR to see who has accessed it.
    1. Please indicate if you wish to:
    • Receive a photocopy of the record.
      • A base fee of $______ per page applies for each page copied.
      • Please enclose an initial payment of $__________ with your request. You will be provided with an estimate of any additional costs.
      • Would you like to receive the copies by bonded courier at your expense or you will pick up the records in person.
    • View the original record, without receiving a copy.
      • The estimated fee you will be charged  $________ for a review of the record by your physician and / or another person
    • Someone will review your chart with you. Circle if you would like your physician or a designated staff person as you review the record
     
     

    _________________________________________   ________________ 
                       Signature of Patient or Authorized Person                                      Date  

    Office Use:

    Confirmation of identity by driver��s license, passport, other government issued photo ID, or known to clinic.

    DATES

    ACCESS REQUEST RECEIVED

    • Notice of Extension Sent, include HIPA reference that authorizes the extension:
    • Notice of Refusal Sent, include HIPA reference that authorizes the refusal:

        Refused in its entirety   

        Refused in part

    ACCESS REQUEST COMPLETED 
     

    Signature of Physician _____________________________  Date

     

    Request for Amendment Form

     

    Purpose: This form may be used when a patient or authorized representative wants an amendment to a medical record.  These requests must be made in writing.  If a physician will accept a request for amendment using a format other than this form it should be documented in the written policy. 

    The information on this form will be used to respond to your request for amendment to your personal health information or the personal health information of someone whom you are legally entitled to represent.  

    Name of Patient 
    Last Name    First Name 

    Other names the information may be under, e.g. maiden name 

    This information will be used in confirming the correct record

    Health Service Number: _______________ Date of birth (dd/mm/yy): _______________

    Name of Physician _________________________

     

    Contact Information

    Street address: _____________________________________

    City /town: ______________________________ Prov.______

    Postal code: ___________________

    Tel: (home) _____________________ (mobile) _________________

     

    This request is being made by an Authorized Representative

    Last Name    First Name

    Street address: _____________________________________

    City /town: ______________________________ Prov.______

    Postal code: ___________________

    Tel: (home) _____________________ (bus) _________________

    The person requesting the personal health information is authorized under HIPA or has authority to access this information under _____________ (name of legislative or court authority).  Attach signed consent or other legal authorization for the applicant to represent the patient. 
     
     
     
     

     
    Details of Request
     
     

    Please describe, in as much detail as possible, the information you are requesting be amended. Please be aware that if the clinic agrees to make an amendment following your request that amendment will not remove the original information from the record, however when the record is read the amendment will be clearly visible. If your requested amendment is not made in the record, your record will contain a notation that you requested the amendment but that the requested amendment was not made. 
     
     
     
     
     
     
     

      

    Signature of Patient or Authorized Representative                                  Date (dd/mm/yy)

     
     
     
     
     

    OFFICE USE

     

    Confirmation of identity by driver��s license, passport, other government issued photo ID, or known at clinic.

     

    DATES

    • AMENDMENT REQUEST RECEIVED:
      • Notice of Amendment Sent to Patient:
      • Notice of Notation in the Record Sent to Patient
      • Notice to Other Trustees Sent
    • AMENDMENT REQUEST COMPLETED 

      Request Denied

      • Information not created by clinic
      • Information is accurate and complete
      • Information is not part of patient record
      • Applicant cannot legally act on behalf of individual
     

    Name of Physician__________________________________________

     

    Comments_____________________________________________________

     

    Signature_______________________________ Date____________________

     

     

      Consent Directive and Masking Form

    Purpose: This form can be used when a patient or authorized representative wishes to limit access to their personal health information and in particular when requesting masking

     

     
     
     
     

    I, _________________________________, wish to limit/revoke my consent to any further use or disclosure by [name of clinic or physician] of my personal health information.  The specific information this directive applies to is: (description of information).

     
     
     
     

    I wish to place the following conditions on any further use or disclosure of my personal health information: (Please specify condition(s))

     
     
     
     

    I understand that this limitation/revocation of consent does not have a retroactive effect nor does it affect the uses and disclosures of my personal health information collected by [name of clinic or physician] where the uses and disclosures are permitted or required by law without consent.

     

    ___________ has explained to me the possible consequences to my timely care because of this consent directive. I also understand that when personal health information is masked the mask can be removed when necessary without my consent.

     
     

    Signature of Patient or Authorized Representative_______________________________

     
     

    Signature of Health Professional: ________________________

     

    Date: _____________

     
     

    Withdrawal of Consent Directive

     

    I hereby withdraw my consent directive.  I do this voluntarily and without coercion.

     
     

    Signature of Patient or Authorized Representative_______________________________

     

    Signature of Health Professional: ________________________

    Date: _____________

     

    Consent Directive and Masking Form

     

    Name of Patient 
    Last Name    First Name

     

    Other names the information may be under, e.g. maiden name

     

    This information will be used in confirming the correct record

    Health Service Number: _______________ Date of birth (dd/mm/yy): _______________

    Name of Physician _________________________

     

    Contact Information

    Street address: _____________________________________

    City /town: ______________________________ Prov.______

    Postal code: ___________________

    Tel: (home) _____________________ (mobile) _________________

     

    This request is being made by an Authorized Representative

    Last Name    First Name

    Street address: _____________________________________

    City /town: ______________________________ Prov.______

    Postal code: ___________________

    Tel: (home) _____________________ (bus) _________________

     

    The person placing the consent directive on the personal health information is authorized under HIPA or has authority to access this information under _____________ (name of legislative or court authority).  Attach signed consent or other legal authorization for the applicant to represent the patient.

     
     

    OFFICE USE

     

    Confirmation of identify by driver��s license, passport, other government issued photo ID, or known at clinic.

     

     

      Breach Notification Letter

    Purpose: This sample letter can be used to notify a patient of a breach of their privacy.  It needs to be adapted to address the specific factors of the breach.

     
     

        Forest Medical Associates

        456 Winter Trail

        Marsh, Saskatchewan

     

      Dear

     

      We are writing to inform you of an incident involving your personal health information on [Date of Breach].  We are notifying you in as timely a manner as possible so you can take swift personal action along with the steps taken by Forest Medical Associates to reduce or eliminate potential harm to you.

     

      The incident involved (brief explanation of what happened).  The personal health information that may have inadvertently been disclosed was: (identify the specific PHI disclosed).

     

      As a result of this incident, we have taken the following corrective actions to prevent a similar incident from occurring: [explain immediate and long term action].

     

      We regret that this breach of your personal health information occurred and wish to express our sincerest apology for any inconvenience or concern that this incident may have caused you.

     

      You may wish to take your own steps to minimize any possible harm to you by taking precautions that include

      • [list possible steps the patient may take]
     

      You may also contact the Office of the Information and Privacy Commissioner at 

      Saskatchewan Information and Privacy Commissioner 
      503 -- 1801 Hamilton Street 
      Regina, Saskatchewan 
      S4P 4B4

      Telephone:  (306) 787-8350 
      Toll Free Telephone (within Saskatchewan): 1-877-748-2298

     

      We, at Forest Medical Clinic take very seriously our role of safeguarding your personal health information and using it in an appropriate manner for your health care.  We will keep you informed if any additional information regarding the incident becomes available.  In the meantime please do not hesitate to contact me at ________, or the Office Manager at ______ for further information on this incident.

     

     

    Purpose: This form should be used when investigating a privacy or security breach

     

    Saskatchewan EMR Program

    Privacy and Security Breach Reporting Form

    Attach additional sheets if necessary

    Do not include any information that will lead to the identification of the individual(s) whose information has been breached.

     
     
    Date of Report:
     
     
    Date of Breach
     
     
    Name of Physician-Trustee and Contact Number
     
     
    Name of Privacy Officer (if different) and Contact Number
     
     
    Name of Person who first reported incident and connection to Physician-Trustee
     
     
    Name of Clinic/Medical Practice
     
     
    Location of breach (full address)
     
     
    Explanation of breach
     
     
    How was the breach discovered
     
    Is this a breach of personal health information Yes/No

    Explain:

     
    When and how was the breach contained
     
     
    Estimated number of people affected by the breach
     
    Describe the information that was breached �� Name     Yes/No

    ��  HSN     Yes/No

    ��  Other ID/chart number   Yes/No

    ��  Credit Card Number  Yes/No

    ��  Full Address   Yes/No

    ��  Postal Code   Yes/No

    ��  Medical History   Yes/No

    ��  Test Orders or Results  Yes/No

    ��  Images    Yes/No

    ��  Prescriptions   Yes/No

    ��  Referral Letter   Yes/No

    ��  Consultation Report  Yes/No

    ��  Other information (describe)

    Describe the type of harm to the patient(s) that may occur from this breach.
    • Identity theft (loss of HSN, credit card number, etc).
    • Risk of physical harm (loss of information that place an individual at risk of physical harm, stalking or harassment) 
    • Hurt, humiliation, damage to reputation  
    • Financial
    • Loss of business or employment opportunities
    Describe the type of harm that may occur to the trustee, another trustee, eHealth Saskatchewan, Government of Saskatchewan or the profession
    • Breach of contractual obligations
    • Similar breach likely to reoccur in another EMR or in the EHR
    • Failure to meet professional standards  
    Are they any other potential risks
    • Public health and safety
    • Other
    Who else has been notified?
    • Patient(s) (Do no provide name(s))
    • Other Trustee(s) (Provide name(s))
    • eHealth Saskatchewan (Provide name of contact)
    • Office of the Information and Privacy Commissioner 
    • Saskatchewan Medical Association 
    • College of Physicians and Surgeons – Saskatchewan
    • Police (provide contact name) 
    • Insurers
    • Legal counsel
    • Vendor
    • Research Ethics Board
    • Other
     
    Describe the administrative (training, restricted access), technical (encryption, passwords, etc.) and physical (locks, alarm, systems, etc.) security measures that were in place at the time of the breach.
     
     
    Describe any immediate steps taken to reduce the harm resulting from the breach
     
     
    Describe any long-term strategies that will be taken to improve practices at the clinic.
     

     

     

     

    Letter Explaining Refusal or

    Partial Refusal of Access

     

    Purpose:  Trustees are required to send the patient a letter when access to his/her own information has been denied.  This letter is a sample of one that may be used.  HIPA provides for very limited authority for denying access. Select the reason(s) you have denied access from the relevant sections of HIPA listed in the body of the letter below.

     

     
     
     
     
     
     

      Dear

     

      Your request for access to your personal health information made on [date] to [name of physician or clinic] has been refused in accordance with The  Health Information Protection Act, Paragraph 38(1), specifically [select one or more of the following reasons for refusing access to the information].

     

        (a) in the opinion of the [name of trustee], knowledge of the information could reasonably be expected to endanger the mental or physical health or the safety of the applicant or another person;

     

        (b) disclosure of the information would reveal personal health information about another person who has not expressly consented to the disclosure;

     

        (c) disclosure of the information could reasonably be expected to identify a third party, other than another someone at the clinic, who supplied the information in confidence under circumstances in which confidentiality was reasonably expected;(e) the information was collected principally in anticipation of, or for use in, a civil, criminal or quasi-judicial proceeding; or

     

        (f) disclosure of the information could interfere with a lawful investigation or be injurious to the enforcement of an Act or regulation.

     
     

      The information that cannot be provided to you has been deleted and the rest of the record is now available for you to pick up from [name of person at clinic].

     

      If you have any questions you may speak to [name of physician or privacy officer].  If you disagree with [name of trustee��s] decision not to provide this information to you, you may contact the Office of the Saskatchewan Information and Privacy Commissioner at (306) 787-8350 or 1-877-748-2298.

     

    Letter Referring Access Request to Another Trustee

     

    Purpose:  Trustees are required to send the patient a letter when access to his/her own information has been denied because it was collected from another trustee for peer review, a standards of care committee or for an investigation or discipline by a health professional regulatory body.  This letter is a sample of one that may be used.  HIPA provides for very limited authority for denying access. Select the reason(s) you have denied access from the relevant sections of HIPA listed in the body of the letter below.

     

     
     
     
     
     
     
     

      Dear

     

      Your request for access to your personal health information made on [date] to [name of physician or clinic] has been refused in accordance with The  Health Information Protection Act, Paragraph 38(1), specifically [select one or more of the following reasons for refusing access to the information].

     

        (d) the information was collected and is used solely:

     

          (i) for the purpose of peer review by health professionals, including joint professional review committees within the meaning of The Saskatchewan Medical Care Insurance Act;

          or

          (ii) for the purpose of review by a standards or quality of care committee established to study or evaluate health services practice in a health services facility or health services agency, including a committee as defined in section 10 of The Evidence Act;

          or

          (iii) for the purposes of a body with statutory responsibility for the discipline of health professionals or for the quality or standards of professional services provided by health professionals;

     

      If you would like access to this information please contact [name of original trustee] at [contact information] for access to your personal health information.

     

      If you have any questions you may speak to [name of physician or privacy officer].  If you disagree with [name of trustee��s] decision not to make this information available you may contact the Office of the Saskatchewan Information and Privacy Commissioner at (306) 787-8350 or 1-877-748-2298.

     

      If you have any further questions, please feel free to contact [name of contact at clinic]

     

     

    Letter of Extension

     

    Purpose: Physicians are required to respond to a patient��s request for access to their personal health information within 30 calendar days.  Physicians are allowed one extension of an additional 30 calendar days for a limited number of reasons.  When preparing the letter, physician must include the section of HIPA that allows for the extension.

     

    SAMPLE LETTER

     

    Dear

     

    On [date], [name of clinic or physician] received your request for access to your personal health information [include dates or other relevant information about the actual personal health information requested].

     

    Please be advised that the 30 day time limit for responding to your request has been extended for an additional 30 days and we expect to respond to your request by [date].

     

    The reason for this extension of time is authorized under The Health Information Protection Act, Paragraph 37(1).  [Select the section of HIPA that applies.

     
     

      37(1) (a) the request is for access to a large number of records or necessitates a search through a large number of records or there is a large number of requests, and completing the work within the original period would unreasonably interfere with the operations of the trustee; or

     

      (b) consultations that are necessary to comply with the request cannot reasonably be completed within the original period.

     

    We will contact you as soon as your record is available.

     

    If you have any further questions, please feel free to contact [name of physician or privacy officer] at [telephone number].

     

     

     

     

     

     

     

     

     

     

     

    Letter Confirming Amendment

    Purpose: Physicians are required to send a letter to a patient to confirm that the amendment requested has been made.

     
     
     

    Sample Letter

    Dear

     

    On [date] you requested that an amendment be made to your medical record.  Specifically the request was to [state the request].

     

    This amendment has been made to the record.

     

    If you have any further questions please contact [name of physician or privacy officer] at [telephone and/or email]

     

    Letter Notifying of Notation

     

    Purpose: Physicians are required to send a letter to a patient when a requested amendment has not been made but a notation has been made in the record. 

     

     
     

    Sample Letter

     

      Dear

     

      On [date] you requested that an amendment be made to your medical record. Specifically the request was to [state the request].

     

      [name of physician] has

     

            determined that the information is accurate and complete

     

            Or

     

            determined the information is his professional opinion or a diagnosis.

     

      The amendment has not been made to your record but a note has been added to your record with the information you provided to [name of clinic].

     

      If you disagree and believe that a change should have been made, we will attempt to resolve the matter with you. You may also contact the Office of the Saskatchewan Information and Privacy Commissioner at (306) 787-8350 or 1-877-748-2298.

     

      If you have any further questions please contact [name of physician or privacy officer] at [name of medical practice and telephone number].

     

    Letter Regarding Amendment or Notification to Other Trustees

    Purpose: When a physician makes an amendment or a notation to a record following a

    patient��s request, the physician is required to notify other trustees or person to whom the physician disclosed the amended or notated information to in the previous year.

     
     
     
     

    Sample Letter

     

      Dear

     

      As required under The Health Information Protection Act paragraph 40(4) this is notice that [name of clinic] has received a request from [name of patient] to amend their personal health information.  We have made the requested amendment [describe the information to be amended]. 

     

      This information was disclosed to you on [date] for [state purpose]. Please make a similar amendment in your records in accordance with The Health Information Protection Act paragraph 40(5).

     

      Or

     

      The requested amendment was not made but the following notation was placed in the record. [Describe notation] Please make a similar notation in your records in accordance with The Health Information Protection Act paragraph 40(5).

     

      Should you have any questions please contact [name of physician or privacy officer] at [telephone number].

     

     Record of Information Holdings

     

    Purpose: If physicians have several holdings of personal health information it is recommended that this be documented along with the location of the holdings and who has access to each holding.  This is an example of record of information holdings.

     
     
    Information Holding Location Access
    EMR database Local server Locally – all physicians have full access

    Students have time limited restricted access

    Employees have restricted access

    Contracted IT support upon request

    EMR Database backup EMR Vendor IT support
    Paper Records Local All physicians

    All staff

    Paper Records Local Storage company – sealed boxes Storage company employees upon request from the

    Office Manager

    Clinical Trial Records Local server Participating physician

    Research nurse

     

     

     

    Record of Destruction of Paper Records

     

    Purpose:  Physicians should maintain a record of the records that are to be destroyed.  This record should be retained in the clinic files and may also be provided to the company destroying the records.  This is a sample of what could be used.

     

    The records described below are eligible for destruction in accordance with the retention and destructions policies of the [Name of Medical Practice].  At the time of destruction all records were stored at [location of storage]

     
     
    Physician Patient Type of Information Years of Information Last Year of Access Date of Destruction
    Dr. Evergreen Primrose

    Small

    Paper Record of patient care 1952-2000 2000 May 2, 2011
     
     
     

    The records will be destroyed by [insert name of person or company] by [insert method] on or before [date].

     
     

    I certify that the records listed above, to the best of my knowledge, are not subject to any current or pending audit, litigation, subpoena, or other legal demand for their retention or disclosure. Further, I attest that the records were retained for [retention period] after the last entry in the record, based on professional requirements and best practices.

     
     

    Signature of Physician

     
     
     

    Signature of Witness

     

    Date

     
     
     
     
     
     
     
     
     
     
     
     
     
     

    PERSONAL HEALTH INFORMATION DISCLOSURE CONSENT

     
     
     
     

    I, _________________________________, consent to the disclosure of my personal health

     
     

    information to ___________________________________.

     
     

    The purpose of this disclosure is to assist in the arranging, assessing the need for, providing,

     
     

    continuing, or supporting the provision of, a service requested or required by myself.

     
     

    Further to this, I understand that this consent is voluntary and can be revoked at any time. 

     
     
     

    Signature of Patient _______________________________

     
     

    Signature of Health Professional: ________________________

     
     

    Date: _____________

     
     
     
     

    Withdrawal of Consent Directive

     

    I hereby withdraw my consent directive.  I do this voluntarily and without coercion.

     
     

    Signature of Patient _______________________________

     
     

    Signature of Health Professional: ________________________

     
     

    Date: _____________

     
     
     

    Patient Email Communications

    Question and Answer Fact Sheet

     

    The following questions and answers are guidelines for utilizing email as a method of communication with your healthcare provider.

     

    What are my risks when using email?

      Email transmission is not guaranteed to be secure or confidential; unauthorized individuals may be able to intercept, read and possibly modify e-mail you send or are sent by your physician or clinic.

      Email may inadvertently be sent to wrong destinations or to the wrong individual.

      Employers may monitor email sent or received by employer-owned systems.

      Email can be used to spread viruses, some of which may cause unauthorized email distribution.

      Email can be forwarded without the authorization or detection of the source author.

    Shared family email accounts can jeopardize confidentiality.

     

    When is it okay for me to use email?

    Email should only be used for non-urgent issues such as routine enquiries or appointment information. Never use email for communication of serious, urgent or time-critical medical issues like suffering from chest pain or severe low blood sugar levels. We do not advise using email when discussing sensitive information such as sexually transmitted diseases, mental health problems, drug treatment or alcohol-related disorders.

     

    How should I format an email?

      • Type ��CONFIDENTIAL�� and the reason for the communication in the Subject line. Example: ��Subject: CONFIDENTIAL – Medical Question��

       • State your message simply and include the following:

         o your full name

         o telephone number (where we can reach you)

     

    How soon will I hear back from my provider?

    Your health care provider and/or staff will do their best to respond to email communications in a timely manner. If you don��t hear back within a few days, please phone your health care provider.

     

    How will the information in my emails be used?

    The information within your email may be shared with other health care providers as part of your care team or staff at the clinic on a need to know basis. Your health care provider and their staff will not, however, share emails with third parties not involved with your care without your prior written consent, except as authorized or required by The Health Information Protection Act (HIPA). Please keep in mind that all emails, sent or received, may become part of your health record.

    What should I do if I change my email address?

      You must notify your health care provider as soon as possible to maintain confidentiality.

       Also��

    Instead of creating a new email, be sure to click REPLY when responding to your health care providers email. This establishes an email trail that allows you and your health care provider to track messages, as well as eliminates the need for entering the return email address, therefore reducing chances of entering an address incorrectly. For your own records, you may want to save copies of messages sent and received within your email program.

     
     
     

    **If you have any questions or concerns, please contact your health care provider**

     

    Patient Email Communications Consent Form

    TRONIC MAIL/FAX CONSENT FORM

     

    Patient Name_______________________________________________HSN____________________

     
     

    Email address(es)_____________________________________________________________________

     

    Home phone___________________________ Work phone__________________________________

     
     

    I, _________________________________, request and authorize Dr. ___________________ and/or his/her staff to communicate information with me regarding aspects of my healthcare through the above email address(es). My signature below denotes that I have read the document, Patient Email Communications – Question and Answer Fact Sheet, and accept the risk of loss of privacy of confidential health information associated with email communication.

     

    I agree that Dr. _________________________________ and his/her staff shall not be liable for any type of damage or liability arising from or associated with the loss of confidentiality due to email communication that is not caused by the health care provider��s or their staffs intentional misconduct. I understand my health care provider will use reasonable means to protect the security and confidentiality of email information sent and received. However, because of the risks outlined in the Question and Answer Fact Sheet, Your health care provider cannot guarantee the security and confidentiality of email communication. Further, I understand that my health care provider does not guarantee this means of communication will be free from technological difficulties including, but not limited to, loss of messages and delay of transmission.

     

    This authorization for communication by means of email is valid until I notify the health care provider listed above, in writing, that I no longer authorize the use of email to communicate information concerning my healthcare. I understand that information communicated by email may be retained within my health record. My health care provider also retains the right to terminate email as a communication option if it becomes burdensome or is used inappropriately.

     
     

    Signature of Patient/Substitute Decision Maker:_______________________________________

     

     

    Date:_____________________________________

     
     
     
     
     

    * Retain copy in patient��s health record


     

       
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