It’s easy to be intimidated by healthcare professionals. We see them for roughly 10-15 minutes at a time and often after a period of several months. Even after several months, it can feel like doctors have had little time to review our cases. Medical records are sometimes left incomplete, inconclusive, or even inaccurate. Inaccuracies can be frustrating and problematic, but they can also be corrected. Many people do not realize that they have the legal right to change medical or billing information. Exercising this right not only benefits patients, but practitioners as well.

In 1996, Congress signed into law the Healthcare Insurance Portability and Accountability Act (HIPPA). One of the Act’s principle goals was to “combat waste, fraud and abuse in health insurance and healthcare delivery.” Over the next decade, HIPPA expanded to include numerous patient protections. In 2003, the US Department of Health and Human Services (HHS) initiated the first HIPAA Privacy and Security Rules. The Privacy Rule was intended to give patients improved access to their health data.

Underneath the umbrella of Privacy Rule protections is a patient’s right to change incorrect or incomplete data. Increasingly, the medical field has acknowledged that a patient’s access to their personal health data is not only their right but is also vital to improving the quality of doctor-patient relations and treatment.

The Privacy Rule provides you with the right to inspect, review, and receive a copy of your medical and billing records. If you believe that information in your record is incorrect, you can request a change to your record. Changes must be limited to factual statements. Examples of factual statements include:

• Medical test results
• Phone number
• Name of diagnosis
• Length of appointment

A statement such as “patient appears lethargic” cannot be changed because it is the observation of the doctor rather than fact.

The HIPAA Privacy Rule generally applies to “covered entities” or providers who transmit health information in electronic form i.e. hospitals, doctors, and insurance plans. They may require in advance that you include a reason for your request and that it be in writing. Your provider must act on your request for an amendment no later than 60 days after receipt but may extend by 30 days if a reason for the delay is provided in writing. If your provider does not provide a reason, they must amend the inaccurate or incomplete information. There are a few exceptions. The entity may deny the request if the information:

• Was not created by the provider, unless the individual provides a reasonable basis to believe that the originator of protected health information is no longer available to act on the requested amendment;
• Is not part of the record;
• Would not be available for inspection under 164.524; or is accurate and complete.

Many health facilities provide forms for amendments, such as this form from Cleveland Clinic. However, sending your own written request is also acceptable. A sample of a request could be:

June 30, 2018

Dr. John Smith
123 Smith Street
Smithville, NY 12345

Re: Request to Amend Medical Records;  Patient Name: Jane Jones; D/O/B: 3/15/1985

Dear Dr. Smith:

Pursuant to Title 45 of the Code of Federal Regulations § 164.526, I am requesting an amendment to my medical record.  

The reason for this amendment request is that the report, written by Dr. Smith, on 12/6/18, incorrectly states that I have Type O blood. This is inaccurate. I am requesting that the record be amended to state that I have Type B blood.

Please let me know when this correction has been made in my file.

Thank you,

(signature)

Jane Jones
312-456-7890

If the provider still does not agree to your request, it is your right to submit a “statement of disagreement” that the they must add to your record. Your provider may reasonably limit the length of the statement and also provide a rebuttal statement. Once the amendment or statement of agreement is filed, the provider or plan must make reasonable efforts to inform individuals who have access to the protected information and may rely on it for future reference.

For the complete law, see Title 45 of the Code of Federal Regulations § 164.526.

Guest blogger Rachel Partington is a lawyer living in Rochester, NY. In her spare time, she writes on health and disability, and also runs a support group – Chronic Illness in Young Adults (CIYA). She also teaches Vinyasa Flow Yoga. She has autoimmune hearing loss and POTS.

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