Reviewing your medical records is not only the smart thing to do, it’s your right. It allows you to update any information that may be important to your care or to query your healthcare provider about missing or incorrect prescriptions or test results. exactly.
Historically, medical records were kept and maintained by primary care providers. In recent years, a trend has emerged that patients are responsible for the storage and preservation of their own medical records.
Unless you are in a healthcare system that gives you access to an electronic medical record (EMR), you will need to take steps to request a copy for yourself.
Who can request medical records?
While designed to protect your privacy, HIPAA regulations are so extensive that many vendors are still confused about how to enforce them. This can sometimes make it difficult to get your records, even if you have the right to.
Under HIPAA, you have the right to request medical records under the following circumstances:
- You are the patient or the parent or guardian of the patient whose record is being requested.
- You are the carer or advocate with the patient’s written consent. In some cases, the healthcare provider will provide you with an authorization form that the patient must complete.
Many people assume that only they or their designees can receive copies of their medical records. By law, there are other individuals or organizations that may also have rights.
This includes not only your primary health care provider, but also covered third-party entities that you may have knowingly or unknowingly authorized when signing for a medical condition. personal or registration form. These include not only medical practitioners, but also organizations such as insurance companies, hospitals, laboratories, nursing homes, rehabilitation centers, and bill providers.
Today, some people are even asking for their medical information to be shared with mobile apps (such as those that monitor your heart health or diabetes). Under HIPAA, you have the right to request this with the understanding that the health care provider releasing the information is not responsible for how the mobile application provider uses or secures the information. your information.
For this purpose, you should read any medical registration or admission document to fully understand the rights you are granting and with whom your information may be shared.
What records can be provided?
While you have the right to most of your medical records, there are some records that a health care provider may keep. The age of a particular set of records can also affect their ability to obtain them — most providers, including healthcare providers, hospitals, and laboratories, are required to keep records. keep adult medical records for at least six years, although this can vary by state.
Record retention periods for children are also specified. Depending on the state, children’s records must be kept for three to 10 years after age 18 or 21.
Among the various records that you have the right to obtain:
- Any notes or records that the supplier has created themselves
- Any diagnostic results that the provider has copies of including blood tests, X-rays, mammograms, genetic tests, biopsies, etc.
- Any information provided by another healthcare provider that has been used to directly diagnose and/or treat
If you’re looking for specific tests or admission records, it’s best to order them from a lab or hospital rather than your primary care healthcare provider. They have the potential to be more complete and can even be kept for a longer period of time than a private medical facility.
Record your provider may refuse
There are records that you may be denied access to. These are primarily related to mental health records that a provider’s notes may be considered “shows” rather than diagnoses. It has been argued that disclosing these records could harm the relationship between the health care provider and the patient or be misinterpreted when taken out of context.
With that said, the provider cannot refuse your request because it might hurt your feelings. It can only be refused if the release of the information could force you to harm yourself or others. If denied, the refusal must be provided to you in writing.
By law, there are certain circumstances under which your health information may be withheld, although these limitations can be broadly construed. Including:
- Psychotherapy notes; These are notes recorded by your healthcare provider and may not be included in your medical records.
- Information has been aggregated for use in a lawsuit
If you feel you have been unfairly denied access to specific medical records, you can file a complaint with the Office for Civil Rights (OCR) at the Department of Health and Human Services. . You can do the same if your medical confidentiality is breached.
If OCR agrees that your complaint is justifiable, it will instruct the healthcare provider or facility to take corrective action or enforce resolution if damage is actually done. Complaints must be filed within 180 days of the violation.
The law also prohibits retaliation against part of an insured entity if a claim is filed, such as termination of service or an increase in the cost of service.
How to request your medical records
Most facilities or practices will ask you to fill out a form to request your medical records. This request form can usually be collected at the office or sent by fax, postal service or email.
If the office does not have a form, you can write to make your request. Guaranteed to include:
- Your name
- Social Security Number
- Date of birth
- Address and phone number
- Email address
- List of required documents
- Day of service
- Delivery options (fax, postal, email, in person)
Once the request has been made, you may have to wait a while before the application is actually received. State laws vary but generally require delivery within 30 to 60 days. Remember to keep a copy of the original request and contact your state’s Department of Health if you do not receive the document after several attempts.
Note that you may have to pay for your medical records if you want them delivered on paper, by fax, or electronically. Although the price may change, it must be reasonable.
Furthermore, you have the right to receive records even if you have not yet paid the provider or healthcare facility for the related procedure. Records cannot be held for non-payment, and you cannot be charged an exorbitant fee to compensate for non-payment of services. If money is owed, the health care provider or facility may pursue ways to collect the debt, such as legal action or debt collection services.
For a healthcare provider not much longer
If your healthcare provider retires or is no longer active, all medical records are still required by law. This is relevant even if a healthcare provider has died or has dissolved its practice without selling.
By law, medical records should be transferred to another health care provider who agrees to assume responsibility. If a provider cannot be found, records may be kept at a reputable commercial archiving company.
Similarly, if your healthcare provider has left the facility but the facility is still open, your records must be maintained by the remaining members. If the practice has been sold, the new establishment will be responsible for maintaining the records and responsible if records are lost or mishandled.
Keeping track of your records can sometimes be a challenge, especially if the healthcare provider’s office has closed without transitional details. In this case, there are several things you can do:
- Contact your state or local medical association. Many of these organizations require an annual subscription, they will most likely have the most up-to-date contact information.
- Talk to your health insurance company. If the healthcare provider is still an approved provider, your insurance company will have contact details.
- Contact any hospital where your healthcare provider has performed sessions. Hospitals require healthcare providers to go through a formal process to obtain hospital privileges. Human resources departments will often have details on file.
If all else fails, you may need to recreate your file by contacting the different labs, hospitals, or specialists you used. Your health insurance companies, both past and present, can provide you with details about any claims made on your behalf.
Once you have obtained a copy of your medical records, review them carefully. If you find errors or omissions, you will want to correct them immediately to ensure that they do not affect your future care.
Most vendors will agree to correct actual errors or track reports that should be maintained in your file.
However, this does not extend to the difference of opinion that your healthcare provider has the right to express a medical opinion. This includes notes regarding contributing factors to illness (such as alcoholism or HIV) that you don’t want in your medical records. Changing or omitting a record will not only be ethically problematic, but could also subject the healthcare provider to a lawsuit.
With that said, if you think it is unreasonable to refuse to edit or cause you harm, file a complaint with OCR detailing the dispute. They can review the evidence and decide if repairs are warranted.
A very good word
Knowing what’s in your medical records can be as important as seeing a healthcare practitioner in the first place. If you have access to your electronic medical record, be sure to review it after every good care appointment or visit. It allows you to make corrections as needed and be more actively involved if and when medical treatment is needed.
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