Summary
When you review your medical record you may find something that you believe does not belong in your record. You might also believe that important medical information is missing. If this is the case, you have the right to add information to your medical record to make it more accurate or complete. This right is usually called the right to amend your record.
There are two ways you can amend your medical record:
- You can write a short statement and give it to your provider to add to your medical record under California law or
- You can request that your health care provider amend your record under the HIPAA Privacy Rule.
You do not have the right to have information removed from your record.
Which way should I choose to amend my record?
Both procedures have their advantages. Writing your own short statement is a simpler procedure. But some people feel that having your health care provider amend your medical record makes the information more believable to others. The rules for minors are different than those for adults. Only you can decide which procedure is better for your purposes. Both procedures are discussed in the sections that follow.
How Do I Add a Written Statement to My Medical Record under California Law?
Under California law, after you review your medical record you have the right give your health care provider a short written statement for any item that you believe is incorrect or incomplete. Your statement may be no longer than 250 words for each item that you believe is incomplete or incorrect. Your statement must clearly state that you want the information to be made part of your medical record. Your provider may have a form for adding a written statement. You should use this form if it is available.
Your health care provider must attach your statement to your medical record. They have to include your statement whenever they share the disputed information with someone else.
Does everyone have the right to add a written statement to their medical record?
No. Minors cannot take advantage of California law and just add a written statement to their medical records. California law only gives adults this right. Minors sometimes have the right to request their provider to amend their medical record under HIPAA. You can read the section of this guided titled “How Do I Ask my Health Care Provider to Amend My Medical Record under the HIPAA Privacy Rule?” to get more information about amending your record under HIPAA.
Do I have the right to have information removed from my medical record under California Law?
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.
How Do I Ask My Health Care Provider to Amend My Medical Record under the HIPAA Privacy Rule?
The HIPAA Privacy Rule gives you the right to ask your health care provider to amend your medical record by adding more information to it. 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. Under the HIPAA Privacy Rule, your health care provider is allowed to require that you put your request to amend your record in writing, such as by a letter, fax, or e-mail. Your provider must let you know in advance that this is a requirement. Your provider can also 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, your request to amend your record should include:
- Your name.
- Your address.
- Your telephone number.
- Your email address.
- Your medical record number, if you know it, or your date of birth.
- Date(s) of service (such as the date of treatment).
- 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.
Can my health care provider ask for my Social Security number on my request to amend my medical record?
Yes. Some health care providers use Social Security numbers as a way to identify medical records. If this is the case, your provider may need your Social Security number to locate your medical record in order to amend it. There is nothing in the HIPAA Privacy Rule or the Social Security Act that prohibits a private health care provider from engaging in this practice.
Do I have the right to have information removed from my medical record under the HIPAA Privacy Rule?
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 under the HIPAA Privacy Rule is not supposed to be a chance to dispute a diagnosis. It is meant to give you the chance to amend your record by adding information to it.
As a minor, do I have the right to request my provider 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 you are an emancipated minor, you have the right to amend your own medical record. Similarly, minors who legally consent to certain kinds of medical treatment have the right to amend medical records related to that treatment.
What Happens if My Request to Amend My Record Under the HIPAA Privacy Rule 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 under the HIPAA Privacy Rule?
Generally, within 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 under HIPAA?
Yes. There are times when your health care provider can deny your request to amend your medical record under the HIPAA Privacy Rule. 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 (for example by sending you a letter, a fax or an e-mail). 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. What can I 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 on the grounds that they did not create the medical information that you want to amend.
Of course, you can also give your provider a written statement under California law, as discussed at the beginning of Section 3 of this guide.
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 on the grounds that he didn’t create the information she wants to amend.
What Can I Do under HIPAA 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.
