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<p>A licensee’s policies and practices relating to medical records under his or her control should be designed to benefit the health and welfare of patients, whether current or past, and should facilitate the transfer of clear and reliable information about a patient’s care. Such policies and practices should conform to applicable federal and state laws governing health information.</p> <p>It is the position of the North Carolina Medical Board that notes made by a licensee in the course of diagnosing and treating patients are primarily for the licensee’s use and to promote continuity of care. Patients, however, have a substantial right of access to their medical records and a qualified right to amend their records pursuant to the HIPAA privacy regulations.</p> <p>Medical records are confidential documents and should only be released when permitted by law or with proper written authorization of the patient. Licensees are responsible for safeguarding and protecting the medical record and for providing adequate security measures.</p> <p>Each licensee has a duty on the request of a patient or the patient’s representative to release a copy of the record in a timely manner to the patient or the patient’s representative, unless the licensee believes that such release would endanger the patient’s life or cause harm to another person. This includes medical records received from other licensee offices or health care facilities. A summary may be provided in lieu of providing access to or copies of medical records only if the patient agrees in advance to such a summary and to any fees imposed for its production.</p> <p>Licensees may charge a reasonable fee for the preparation and/or the photocopying of medical and other records. To assist in avoiding misunderstandings, and for a reasonable fee, the licensee should be willing to review the medical records with the patient at the patient’s request. Medical records should not be withheld because an account is overdue or a bill is owed (including charges for copies or summaries of medical records).</p> <p>Should it be the licensee’s policy to complete insurance or other forms for established patients, it is the position of the Board that the licensee should complete those forms in a timely manner. If a form is simple, the licensee should perform this task for no fee. If a form is complex, the licensee may charge a reasonable fee. </p> <p>To prevent misunderstandings, the licensee’s policies about providing copies or summaries of medical records and about completing forms should be made available in writing to patients when the licensee-patient relationship begins.</p> <p>Licensees should not relinquish control over their patients’ medical records to third parties unless there is an enforceable agreement that includes adequate provisions to protect patient confidentiality and to ensure access to those records.*</p> <p>When responding to subpoenas for medical records, unless there is a court or administrative order, licensees should follow the applicable federal regulations.</p> <p><em>[*] See also Position Statement on Departures from or Closings of Medical Practices.</em> </p> <a href="http://www.ncmedboard.org/position_statements/detail/access_to_medical_records/" title="Access to medical records">Visit Article</a>

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What month follows May?