____________________________________________
Date
Cameron University
Health Plan
Denial of Individual’s Request for Protected Health Information
Member Name:
Member Address:
The request you submitted for access to certain protected health information maintained in a designated record set by the University’s Health Plan above
has been denied, in whole or in part, for the reason indicated below:
1. Information Not Available: The Health Plan does not have the information you requested. The information you requested may be
obtained from . (Alternative location will be provided, if known.)
2. Legal Information: All or a portion of the information you requested has been compiled in reasonable anticipation of, or for use in, a
civil, criminal, or administrative action or proceeding.
3. Inmate Information: Releasing a copy to you would jeopardize the health, safety, security, custody, or rehabilitation of you or other
inmates, or the
safety of any officer, employee, or other person who is at the correctional institution or who is responsible for your
transportation.
4. Research: As you agreed by signing the research participation form(s), your access to the protected health information created or
obtained
in the course of the
research has
been temporarily suspended. The suspension will last for the time indicated in the
form(s)
you signed.
5. Information from Other Source: The information you are requesting was obtained from someone under a promise of confidentiality,
and the access requested would be reasonably likely to reveal the source of the information.
6. Endangerment: A licensed health care professional has determined that the access you requested is reasonably likely to endanger the
life or physical safety of you or another person. You may request a review of a denial for this reason.
7. Reference to Other People: The information you requested makes reference to another person and a licensed health care
professional has determined, in the exercise of professional judgment, that the access requested is reasonably likely to cause
substantial harm to such other person. You may request a review of a denial for this reason.
8. Personal Representative: A licensed health care professional has determined that the provision of access to the information you
requested as the Member
’s Personal Representative is reasonably likely to cause
substantial harm to the
Member
or another person.
You may request a review of a denial for this reason.
9. Psychotherapy Notes: Your treating health care provider has not approved the release of your psychotherapy notes.
10. Other:
Information that is not subject to one of the reasons for denial listed above will be provided to you as requested.
Right to Review:
If a right to review is available as indicated in items 6, 7, and 8 above, you may request a review of the denial from the health care provider who denied
your initial request. Your request will be reviewed by a licensed health care professional who was not involved in this denial within thirty (30) days after
receiving the written request for review. The determination of this individual will be final. You will be notified promptly, in writing, of the decision.
Complaints:
You may file a complaint regarding the University Health Plan’s compliance with the HIPAA Privacy Regulations with the Secretary of the Department of
Health and Human Services (1301 Young Street, Suite 1169; Dallas TX, 75202) or any other agency that has been delegated the responsibility to enforce the
Privacy Regulations. You may also submit a complaint to the Health Plans Privacy Official by calling (405) 271-2511 or sending an email to
OUCompliance@ouhsc.edu. You may submit an anonymous complaint by calling the University’s Compliance Hotline (405) 271-2223 or 1-866-836-3150.
Signed
File in Member Chart HIPAA Document
Rev. 1/2015 © 2015 Send copy to Privacy Official Retain for a minimum of 6 years
