36C77619R0003-0003003.pdf

VHA Office of Informatics and Information Governance

Data Quality, Healthcare Identity Management (HC IdM)

Identity Management Fact Sheet Updated: July 9, 2018

Identity Trait Changes

This fact sheet provides guidance to the field on the requirements for person identity trait changes within the Master Veteran Index (MVI).

Updates to identity traits can only be made in the event that the information is found to be incorrect or due to a legal change. A person’s legal and documented identity traits need to be captured to enable accurate identification. Identity trait updates can be divided into two major categories:

1. Administrative Corrections: Updates to correct typographical errors or misspellings in the Name, Social Security Number (SSN), Birth Sex, or Date of Birth (DOB) fields do not require processing by the Healthcare Identity Management (HC IdM) Team and should be corrected at the facility or application level. Once proper verification has been obtained with the accurate identity trait data (Name, SSN, Birth Sex, or DOB), the correction can be made at the site. Per VHA Handbook 1907.01, Health Information Management and Health Records, “Administrative correction is the documentation by administrative personnel with the authority to correct information previously captured by or in error.” Please refer to VHA Directive 1906, Data Quality Requirements for Healthcare Identity Management and Master Veteran Index Functions for appropriate identity trait data entry requirements.

If the person claims to never have had a first or middle name, a Birth Certificate is required for removal.

Please confirm the Multiple Birth Indicator (MBI) value is accurate before making an administrative correction to the SSN field as persons who are part of a multiple birth and received their SSN cards prior to June 25, 2011 may have similar SSNs in addition to other traits being similar or the same (i.e., last name, DOB, Mother’s Maiden Name).

If the correct data has been verified and updated in the local VistA system or application and it reverts back to the incorrect data, then the local MVI Point of Contact (POC) will need to enter a Person Verification Task in the Identity Management Toolkit for the HC IdM Team to assist in applying the update. The MVI POC will need to attach the verification documentation for the correction into the Task. Additional documentation may also be requested when necessary.

Supporting Legal Documentation for a Correction

When making an administrative correction request, the individual must provide at least one of the following un-expired, Primary Identification documents that displays the trait being corrected.

If a secondary Indentification is provided, at least one of the un-expired Primary Indentification(s) must be provided.

Primary Identification Secondary Identification

State-Issued Driver's License with photo Birth Certificate

Passport with photo Social Security Card

Federal, State, or Local Government-issued photo ID containing name and DOB

2. Record Amendments: Legal changes to a person’s Name, SSN or Birth Sex are considered record amendments and require coordination between the facility’s MVI POC, Privacy Officer (PO), and the HC IdM Team. Once an individual or personal representative makes a written amendment request, the MVI POC is responsible for providing the appropriate official supporting documentation to HC IdM for processing via a Person Verification Task in the Identity Management Toolkit.

Appropriate documentation, as identified in the guidelines below, is always required for changes that are not considered corrections but instead are legal changes to identity information.

Additional documentation may also be requested when necessary. (Please refer to the VHA Information Access and Privacy Office’s Practice Brief #2: Request for Amendment of Record under Privacy Law for further information on processing record amendment requests.)

Record Amendments: Name Changes

Identity data, such as a person’s Name, is a key component of the official MVI record. Therefore, it is required that the individual’s current, full legal name, including a full middle name, if applicable, is entered into the record. Retaining the current, full legal name on the MVI record serves to protect the person’s privacy, security, and safety by helping to ensure that correct record selections are made, especially among persons with similar identity traits.

Nicknames or ambiguous information are not to be used in the Name field. A middle initial should only be used if it is the person’s given middle name. Complete removal of any name component or changing any full name component to an initial requires an official name change court order.

Removing a Suffix is also considered a record amendment.

Supporting Legal Documentation for a Name Change

When making a written amendment request for a name change, the individual must provide at least one of the following un-expired, official supporting documents from the list below with the new name:

Identification

State-Issued Driver's License with photo

Passport with photo

Federal, State, or Local Government-issued photo ID containing name and

DOB

Social Security Card (Must be accompanied by an un-expired government issued photo ID that includes either the old or the new name)

Court Order for a Name Change (Must be accompanied by an un-expired government issued photo ID that includes either the old or the new name)

NOTE: Marriage licenses or certificates are not sufficient documents for a name change, as not all people who apply for a marriage license or marry actually change their name.

Record Amendments: Social Security Number (SSN) Changes

The person’s current official SSN issued by the Social Security Administration (SSA) should be entered into the record. Fictitious SSNs are not to be created, and no other numbers may be entered in this field including prison-issued numbers or Canadian SSNs. If a valid SSN is not known or the person refuses to provide a SSN, then a "P" must be entered into the field for the calculation of a pseudo SSN.

An amendment request to completely remove a previously entered valid SSN will generally be denied based on the fact that the SSN is accurate, complete, relevant and timely per the Privacy Act of 1974 [5 U.S.C. §552a (d)] [38 C.F.R. 1.579] record amendment regulations.

If the person has a Department of Defense (DoD) issued Temporary ID Number (TIN) or Foreign ID Number (FIN) rather than a SSN, a pseudo SSN will need to be entered into the SSN field as noted above in order to establish the record. The TIN or FIN field should then be edited via Fileman to reflect the number provided by the person. A TIN is used for individuals (e.g., babies) who do not have or have not provided a SSN to DoD. It is used for military dependents only. A FIN is used for foreign military and foreign nationals.

Supporting Legal Documentation for an SSN Change

An amendment request to change the SSN requires that the individual submit the request in writing along with one form of un-expired Primary Identification and one form of Secondary Identification that displays the current SSN. The Primary Identification verifies the person’s identity and the Secondary Identification verifies the updated SSN.

State-Issued Driver's License with photo Social Security Card

Passport with photo Letter from SSA with updated SSN

Federal, State, or Local Government-issued photo ID containing name and DOB

Record Amendments: Birth Sex Changes

The documented Birth Sex in the electronic health record (Computerized Patient Record System [CPRS], MVI, and VistA) should be consistent with the patient’s original birth certificate. This allows for automatic Clinical Reminders, lab results, medication dosages, etc. to provide correct values within CPRS and provide optimal care for all Veterans.

In order to alleviate the need for changing the Birth Sex from its original value on patient records, a new field has been added to VistA and the MVI called Self-Identified Gender Identity (SIGI). This field is intended to signify the Veteran’s gender preference for use by VA staff to determine the appropriate way to communicate with the Veteran. This field is available for updating in VistA and will display within MVI and many other VA applications in time. The SIGI field may be set as desired by the Veteran, and requires no documentation for updates.

NOTE: If the patient is requesting their changed Birth Sex be restored to the birth sex on their original birth certificate and a previous Toolkit Request was submitted to HC IdM, with appropriate documentation, no additional supporting identification is needed. The only supporting documentation needed is the patient’s written request to have this field reflect the sex on their original birth certificate, which must be submitted to HC IdM as a Toolkit Person Verification Task.

Supporting Legal Documentation for a Birth Sex Change

Despite the medical implications, some Veterans will want to change their Birth Sex field to reflect their identity and this is the Veteran’s right. Surgery is not a prerequisite for amendment of Birth Sex. A Veteran’s request for amendment to Birth Sex in the record is considered a Privacy Act “amendment request.” An amendment request to change the Birth Sex requires that the individual submit the request in writing along with one form of un-expired Primary Identification and one form of Secondary Identification that displays the current Birth Sex. The Primary Identification verifies the person’s identity and the Secondary Identification verifies the updated Birth Sex.

State-Issued Driver's License with photo Amended Birth Certificate

Passport with photo Court Order for Birth Sex Change

Federal, State, or Local Government-issued photo ID containing name and DOB

Signed Licensed Physician’s Statement on Office Letterhead (see requirements below)*

*An original statement from a licensed physician must include ALL of the following information:

• Physician’s full name

• Medical license or certificate number

• Issuing state of medical license/certificate

• Address and telephone number of the physician

• Language stating that he/she has treated the person or reviewed and evaluated the medical history of the applicant. He/she also has a doctor/patient relationship with the applicant which is evident in having one or more clinical encounters between doctor and patient.

• Language stating that the patient has had appropriate clinical treatment for Birth Sex transition to the new Birth Sex (specifying male or female).

• Language stating “I declare under penalty of perjury under the laws of the United States that the foregoing is true and correct.”

References VHA Directive 1906, Data Quality Requirements for Healthcare Identity Management and Master Veteran Index Functions VHA Information Access and Privacy Office’s Practice Brief No. 2, Request for Amendment of Record Under Privacy Law VHA Directive 1605.01, Privacy and Release of Information VHA Handbook 1907.01, Health Information Management and Health Records VHA Directive 2012-036, Identity Authentication for Health Care Services VHA Directive 2013-003, Providing Health Care for Transgender and Intersex Veterans

Rescissions November 2016 September 2016 May 2018

Contact Information:

Contact the HC IdM Team via the Identity Management Toolkit, or if you do not have access to the Toolkit please contact your site’s MVI POC for assistance. A listing of the MVI POCs can be found at:

https://mvitk-prod.aac.va.gov:8957/imdquiWeb/pocMgtRead.do.

http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2880 http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2880 http://vaww.vhaco.va.gov/privacy/FactSheets.htm http://vaww.vhaco.va.gov/privacy/FactSheets.htm https://mvitk-prod.aac.va.gov:8957/imdquiWeb/pocMgtRead.do