Amending Your Medical Records
The HIPAA Privacy Rule ensures a patient’s right to ask that their medical record be amended but it is up to the clinician to decide whether to approve these changes. In other words – you can ask, but there is no guarantee your wishes will be granted. Regardless of whether the answer is yes or no, HIPAA obligates your clinician to respond in writing to their patient’s request.
Why would I amend my medical records?
Patients can ask to amend their medical or billing records if they believe that the information in their records is incorrect or incomplete.
How do I request an amendment to my medical records?
Most hospitals and medical practices have specific procedures for requesting an amendment to your medical records and may require your request be made in writing. When requesting an amendment, be prepared to provide information such as your email address and telephone number, a description of the medical information that you believe is incorrect, details about what you want to be added or removed and why. It is important to be clear and concise; the goal is to make it easy for your clinician’s office to make the changes you want.
Why might my clinician deny my request to amend my medical record?
Your clinician can deny your request if, in their professional judgment, they determine that your records are correct and complete, or if they were not the medical professional who created the information you want changed, or if the requested change is not part of the records that they maintain.
How will I know if my request is denied?
Your clinician must provide a written denial outlining in plain language the reason for the denial. Your clinician then must allow you to submit a statement of disagreement that will be included in your medical records. Patients may not remove information from their medical records themselves, nor is it permissible to amend your records if you are not in agreement with a diagnosis.
What happens if my amendment request is approved?
You will be notified in writing if your request is approved. Your clinician has 60 days after receiving the request to add the amended information to your medical record. Your clinician must also inform any additional individuals that you indicate need access to your medical records of the updated information. Additionally, if your clinician is informed by another healthcare professional involved with your care that an amendment has been made to your medical record, your clinician must make the amendment as well.
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