When you read your medical record you may find something that you believe is not accurate. You might believe that important information is missing. You have the right to correct your medical record by having information added to your record to make it more complete or accurate. The HIPAA Privacy Rule calls this right the right to amend your medical record.
If your health care provider accepts your request to amend your record, they must add the information to your record.
If your provider denies your request to amend, they must tell you. You then have the right to add a short statement to your record that explains your position.
As a minor, do I have the right to amend my medical record under the HIPAA Privacy Rule?
Sometimes. As a minor, you usually do not have the right to amend your medical record. The right to amend (like the right of access) usually belongs to your parents.
However, if, as a minor, you legally consent to medical treatment (and the consent of your parents is not required for that treatment) you also have the right to amend medical records related to that treatment.
How Do I Ask My Health Care Provider to Amend My Medical Record?
Before you ask your health care provider to amend your medical record, you should:
- Identify the part of your medical record that you think is inaccurate or incomplete.
- Identify the health care provider that created the information or that first put the information into your record.
You should ask your provider about their specific procedures for requesting an amendment to your medical record. Your health care provider may have a form for requesting an amendment. You should use this form if one is available. You should be able to find some information about amending your medical record in your provider’s notice of privacy practices.
Can my health care provider require that I put my request to amend my record in writing?
Yes. Your health care provider is allowed to require that you put your request to amend your record in writing. They are also allowed to require that you give them a reason why you want to amend your record.
What information must be included in my request to amend my medical record?
If your provider does not have a form for requesting your medical record, you should check to see what information your provider requires. Generally, you may want to include the following information in your request:
- The date of your request.
- The name of the health care provider to whom you are directing your request.
- Your name, address and other information about where they can contact you.
- Your date of birth or medical record number.
- The type of information you want to amend (such as lab results).
- A description of the information that you believe is inaccurate or incomplete
- The information that you want them to add to your record.
- The reason why you want the information added.
- Your signature.
Can my health care provider require that I include my Social Security number in my request to amend my medical record?
Yes. Because some health care providers use Social Security numbers as a way to identify medical records, they may need your Social Security number to locate your medical record. There is nothing in the HIPAA Privacy Rule or the Social Security Act that prohibits a private provider from engaging in this practice.
Do I have the right to have information removed from my medical record?
No. You do not have the right to have information that is already in your record removed or altered. You only have the right to add more information.
I disagree with my provider’s diagnosis. Can I make them change it?
No. The right to amend your record is not supposed to be a chance to dispute a diagnosis. It is meant to give you the chance to correct your record by adding information to it.
What Happens if My Request to Amend My Record Is Accepted?
If your health care provider accepts your request to amend your medical record, they must add the new information to your record. They also must tell you in writing that your request to amend was accepted.
You might know people or organizations that should be told about the new information. You should give their names and contact information to your health care provider. Your provider must give the amended health information to the people and organizations you identify.
How long Should it Take to Amend My Medical Record?
Generally, no later than 60 days after they receive your request, your health care provider must either
- Add the information to your medical record as you requested or
- Deny your request in writing.
Can it ever take longer?
Yes. If your health care provider is unable to act within 60 days, they can get one 30-day extension to respond. In order to get this extension, they have to give you a written explanation for the delay and tell you the date they expect to respond. Even with an extension, they shouldn’t take more than 90 days to respond to your request to amend your record.
When does the 60-day time period begin?
The 60 days does not start until your health care provider receives your request to amend your medical record. If you mailed your request, you should make sure you include some additional time for mail delivery when you count days for these deadlines.
Can My Health Care Provider Deny My Request to Amend My Medical Record?
Yes. There are times when your health care provider can deny your request to amend your medical record. Generally, your provider can deny your request when:
- They determine your record is accurate or complete.
- They did not create the information that you want to amend.
If your health care provider denies your request to amend your record, they must let you know in writing. Your provider also must tell you why they denied your request.
The provider that created the information that I want to amend isn’t around any more. Is there anything I can do?
You can ask your current provider to amend your information. You should explain to them in as much detail as possible that the health care provider who first created the information that you want to amend is no longer available to act on your request. If your explanation is reasonable, your current provider cannot deny your request to amend just because they did not create the medical information.
Brianna wants to amend information in her medical record that was originally put in her record by Dr. Smith. Dr. Smith has retired. Brianna asks Dr. Jones, her current doctor, to amend her medical record. She shows Dr. Jones the letter Dr. Smith sent to his patients announcing his retirement. Dr. Jones cannot refuse to amend Brianna’s record just because he didn’t create the information she wants to amend.
What Can I Do if My Request to Amend My Medical Record is Denied?
If your request is denied, you have the right to give your health care provider a written statement that explains why you disagree with their decision. Your provider may reasonably limit the length of your statement. Your provider must make your statement part of your medical record. In the future, when your provider shares your medical information with others, your provider must also give them a copy of their denial of your request to amend and a copy of your statement of disagreement.
What if my health care provider disagrees with my statement of disagreement?
If your health care provider disagrees with your statement, they have the right to put a note in your record that says why they do not agree with you. They must give you a copy of this note.
Do I have the right to have someone else review my health care provider’s denial of my request to amend my records?
No. If your health care provider denies your request to amend your medical record you do not have the right to have someone else review that decision.