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ATTACHMENT 6

Office of Informatics and Analytics VHA Privacy Office Privacy Fact Sheet October 2008 – Revised November 2012 Volume 08, No. 9

Use of Full Legal Name and Requests for Name Changes

This fact sheet addresses the requirements for using the full legal name and the requirements for name changes as it relates to data quality for identity management and Master Veteran Index (MVI) operations at VHA health care facilities. It will also address requests to remove a middle name or a middle initial for enrollment or health care purposes.

Full legal name is defined as an individual's first name, middle name(s), and last name or surname, without use of initials or nicknames.”

Name: The NAME field is an important element in the unique identity of a person. Sites need to ensure that the name entered is the full legal name, and includes a full middle name, when available. Nicknames or ambiguous information are not to be used.

Name Change: Supporting Documentation When an individual makes a written request for a name change one of the following official supporting documents are required:

· letter from the Social Security Administration (SSA) stating that all required documentation has been received and they will be issuing the requestor a new SSA card

· a valid State Driver’s license/State issued ID card (based on the fact that the Departments of Transportation will NOT change names until SSA has provided the above letter or new SSA card)

· new SSA card with the name change

· an official name change court order

· amended birth certificate or

· valid passport

Expired documents are not acceptable.

**Note: Marriage licenses or certificates are not sufficient stand-alone documents for a name change as not all people who apply for a marriage license or marry actually change their name. Also, new immigration laws have strengthened the Department of Transportation requirements to verify identity prior to issuing driver’s licenses/ID cards.

Middle Name Removal:

The request to remove a name is not processed the same as a request to change a name. An official name change court order is required for removal of a middle name. However, in cases where the patient claims to never have had a middle name, a Birth Certificate is required for removal.

Is a Veteran required to provide VHA their entire middle name or can they only provide the middle initial? The Veteran is required to provide their complete legal proper name, which includes full middle name.

What if the patient states they have no middle name? Some Veterans do not have middle names. The middle name will be left blank if one does not exist.

How does a Veteran request a name change at the facility? The Veteran must request in writing an official name change. Official documentation is required for all name change requests and some requests may not be granted. This written request will be processed as an amendment request unless it involves only a typographical error and a correction can be made. If the existing name is accurate, timely, relevant and complete, the request to remove or change the name will generally be denied.

NOTE: The process for amending the health record can be found in VHA Handbook 1605.1, Privacy and Release of Information, Paragraph 8 and also on the VHA Privacy Office Web site http://vaww.vhaco.va.gov/privacy/vhapo.htm fact sheet and minutes tab.

Who processes requests for official name changes? Once the official supporting documentation has been received by the site and reviewed for accuracy, the Privacy Officer will work with the MVI Points of Contact (POC). Each facility has designated individuals as MVI Points-of-Contact (POC’s) responsible for processing exceptions, performing other MVI-related tasks and communicating with the national Healthcare Identity Management (HC IdM) Team. A current listing of MVI POCs at each site is available on the HC IdM website: http://vista.med.va.gov/mpi_dqmt/mpi_points_of_contact.htm. The MVI POC is responsible for acquiring the appropriate approval/denial of the amendment request at the local level, before contacting the VHA HC IdM Team for action.

How far back do we go to make names changes to VHA records? If the name change request is granted, the name change will occur prospectively and VHA will not be required to go back and change pre-existing documents.

What happens if a patient prefers to not use a middle name or middle initial any longer and makes an amendment request for this change? Generally, the request would be denied, because the existing information is correct. The VHA Data Quality Program has determined that a complete legal proper name, which includes full middle name, is relevant to the business process of identity management of the patient’s electronic health record to ensure the accurate identity of the Veteran.

References

VHA Directive 2011-024, Providing Health Care for Transgender and InterSex Veterans VHA Directive 2007-037, Identity Authentication for Health Care Services VHA Directive 2006-036, Data Quality Requirements for Identity Management and Master Patient Index Functions

Privacy Office at a glance… VHA-specific: VHA personnel should contact the VHA Privacy Issues mail group for privacy questions or the MVI mail group at VHA HC IdM Team.

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