Both the HIPAA Privacy Rule and Massachusetts law give you rights to your medical record. The HIPAA Privacy Rule sets standards that apply to records held by health care providers across the nation. Massachusetts law sets standards for records held by doctors, hospitals and other health care providers within the state. Most health care providers must follow both the HIPAA Privacy Rule and Massachusetts law. If a standard in Massachusetts law conflicts with a standard in the HIPAA Privacy Rule, your health care provider must follow the law that is the most protective of your rights.
Summary of Your Rights
In Massachusetts you have the right to:
- See and get a copy of your medical record.
Your health care provider usually must let you see your medical record and/or give you a copy of it. Most health care providers, including hospitals, must give you access to your medical record no later than 30 days after they receive your request. Doctors, however, generally must respond to your request for your medical record within 14-21 days.
In many cases, your health care provider is allowed to charge you for copying your record. You can also be charged the actual cost for postage or delivery.
- Correct your medical record by having information added to it.
You have the right to have information added to your medical record to make it more complete or accurate. This right is called the right to amend your record.
- File a complaint.
You have the right to file a complaint with the Office for Civil Rights, U.S. Department of Health and Human Services if you believe your health care provider has violated your right to see, get a copy of, or amend your medical record. You can also file a complaint against your doctor with the Massachusetts Board of Registration in Medicine, the state agency that regulates doctors in your state. Complaints against hospitals can be filed with the Massachusetts Department of Public Health, the state agency that regulates hospitals.
You can learn more about these rights in the following sections of guide.
Who Has to Follow These Laws?
Most Massachusetts health care providers (medical doctors, dentists, optometrists, hospitals and others who provide medical care or services) must follow both the HIPAA Privacy Rule and state laws that give patients rights in their medical records.
There are some health care providers, however, that do not have to follow the HIPAA Privacy Rule. The HIPAA Privacy Rule only covers health care providers that use computers to send health information for certain administrative or financial purposes (such as filing claims for insurance).
Example
Ashley goes to a dentist who does not accept any type of insurance, including Medicaid. The dentist requires all patients to pay directly out of pocket and does not file any insurance claims. Ashley’s dentist probably does not have to follow the HIPAA Privacy Rule because the dentist does not appear to send health information for the types of administrative or financial purposes that would make her a covered health care provider under the Rule.
If you have questions about whether your health care provider must follow the federal HIPAA Privacy Rule, you can contact the Office for Civil Rights, U.S. Department of Health and Human Services (OCR), the agency that is in charge of enforcing the HIPAA Privacy Rule. Section 4 of this guide lists contact information for OCR.
Are nursing homes covered by HIPAA?
Yes. Most nursing homes are covered by the HIPAA Privacy Rule. They also have to follow other specific rules that only apply to nursing homes and long term care facilities. Because the rules for nursing homes are different than they are for other health care providers, they are not covered by this guide.
What if my health care provider does not have to follow HIPAA?
Even if your provider does not have to follow the HIPAA Privacy Rule, they still have to follow Massachusetts laws that give you rights to your medical record. Section 6 lists some resources that where you can read these state laws.
This guide, however, only explains getting your medical record from Massachusetts providers who have to follow the HIPAA Privacy Rule and state law.
What Records Do I Have the Right to Get and Amend?
You have the right to see and get a copy of your medical record. You also have the right to correct your medical record by having information added to it to make it more complete or accurate. This right is called the right to amend your record. (This guide will call these rights the "right to get and amend.")
Your medical record includes such things as:
- Information that identifies you, such as your name and Social Security number.
- Information that you tell your doctor, such as:
- Your medical history.
- How you feel at the time of your visit.
- Your family health history.
- The results of your examination.
- Test results.
- Treatment received in a hospital.
- Medicine prescribed.
- Notes that the doctor or nurse makes about you.
- Other information about things that can affect your health or health care.
You have the right to get these records whether they are kept on paper or on a computer.
Can I keep my original medical record?
Under Massachusetts law, your health care provider is required to maintain the original medical record. You only have the right to see and get a copy of it.
What happens if my medical record has information in it that came from a different health care provider?
Generally, if your provider has the medical information that you request, they must give it to you. You have the right to get the information no matter who originally put it in the record. Your right to amend this information may be limited, though. For more information about the right to amend information in your record you can read Section 3 of this guide.
Do I have the right to get and amend records about my mental health treatment?
Maybe. The rules for when you can get and amend your records about mental health treatment can be different. For example, psychotherapy notes are treated differently than other records under the HIPAA Privacy Rule. Because the rules for mental health records can be different they are not discussed in this guide. You can find some resources that explain your rights in these types of records in Section 6.
Who Has the Right to Get and Amend My Medical Record?
You have the right to see and get a copy of medical records that are about you. You also have the right to correct medical records that are about you by having information added to them. (This guide calls these rights the right to "get and amend" your medical record.) If there is someone who acts as your personal representative, they usually have the right to get and amend your record on your behalf. Generally, a personal representative is a person who has the right to make health care decisions on your behalf.
Do I have the right to get and amend my minor child’s medical record?
Generally, yes. As a parent or guardian, you are usually considered to be the personal representative of your minor child. As a personal representative, you have the right to get and amend your minor child’s medical record. In Massachusetts, you usually have these rights when your child is younger than 18 years old.
As a parent, do I always have the right to get and amend my child’s medical record?
No. A parent does not always have the right to get and amend a minor child’s medical record. For example, if a health care provider reasonably believes that a parent is abusing or neglecting a child, the provider does not have to treat the parent as the child’s personal representative. This means the provider does not have to give the parent access to the child’s medical record.
Some other situations where parents do not have the right to get and amend their child’s medical records are discussed in the following questions and answers.
Who has the right to get and amend my child’s medical record once he or she turns 18?
Once your child turns 18, your child has the right to see, get a copy of, and amend their own medical record. This includes getting access to records that were created when your child was under 18. You usually no longer have the right to get and amend your child’s medical record just because you are her parent.
I am under 18, but I’m considered emancipated under Massachusetts law. Who has the right to get and amend my medical record?
You do. If you are under 18 and are emancipated under Massachusetts law, you have the right to get and amend your own medical record. For example, if you are under 18 and are married, widowed or divorced, you are generally considered to be emancipated for purposes of making health care decisions in Massachusetts. Similarly, if you are in the armed forces you are considered emancipated with respect to consenting to health care. In these cases, you have the right of access to your own medical record.
I am a minor. I am not emancipated but I can legally consent to certain kinds of medical treatment without my parents’ permission. Who has the right to get and amend my records that are related to this treatment?
It depends. In Massachusetts, if you are under 18, you can consent to certain kinds of medical treatment without the permission of your parents. For example, a minor may consent to the treatment for chlamydia (a sexually transmitted disease) without their parents' permission. When you consent to such treatment, you have the right to get and amend your own medical record related to that treatment. In Massachusetts, your parents generally do not have the right to get and amend medical records related to treatment for which you have given consent. However, your provider must notify your parents of your medical condition if it is so serious that your life or health is endangered.
Jason is sexually active and under 18. He consents to get tested for chlamydia (a sexually transmitted disease). Jason’s mother later requests a copy of his medical record. Jason’s health care provider generally cannot give Jason’s mother the part of his record about the chlamydia test without Jason's permission. However, if the doctor believes that Jason's condition is serious enough to endanger Jason's life or health, the doctor must notify Jason's parents.
The rules may be different when you, as a minor, obtain testing or treatment for other medical conditions without parental consent. If you have questions or concerns about whether your parent will have access to your medical information, you should talk to your health care provider.
I am named as my mother's health care agent in her health care proxy. Do I have the right to get and amend her medical records?
Yes. If you are named as the agent in your mother’s health care proxy, you generally have the right to get and amend her medical records that are relevant to making health care decisions on her behalf. You have these rights while you have the authority to make health care decisions on her behalf.
How Long Does My Provider Have to Keep My Medical Record?