Both the HIPAA Privacy Rule and Maine law give you rights with respect to your medical record. The HIPAA Privacy Rule sets standards that apply to records held by health care providers across the nation. Maine law sets standards for records held by medical doctors, dentists, osteopaths, hospitals and other health care providers within the state. Most health care providers must follow both the HIPAA Privacy Rule and Maine law. If a standard in Maine 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 Maine 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 or give you a copy of it no later than 30 days after they receive your request. This right is called the right to access your medical record.
Your health care provider is allowed to charge you a fee for copying your record. They can also charge you the actual cost for postage if you have the copy mailed to you.
- Have information added to your medical record to make it more complete or accurate.
This right is called the right to amend your record. In certain cases, your provider can deny your request to amend your record. If this happens, you have the right to add your own short statement to your medical 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 with the state agency that regulates your health care provider.
You can learn more about these rights in the following sections of guide.
Who Has to Follow THESE LAWS?
Most Maine health care providers (such as doctors, dentists and hospitals) must follow both the HIPAA Privacy Rule and state laws that give patients rights with respect to 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).
Sometimes Ashley goes to a doctor at a free clinic for medical treatment. The doctor does not accept private insurance, Medicaid, or Medicare. The doctor does not file any insurance claims. Ashley’s doctor probably does not have to follow the HIPAA Privacy Rule because the doctor 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 Maine laws that give you rights to your medical record. Section 6 lists some resources where you can read these state laws.
This guide, however, only explains how to get your medical record from Maine 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. This right often is called the right to access your medical record. You also 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. (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.
- Other information about things that can affect your health or health care.
You have the right to see, get a copy of, and amend these records whether they are kept on paper, on a computer, or in other format.
Who owns my medical record?
Under Maine law, your health care provider owns the actual medical record. For example, if your provider maintains paper medical records, they own and have the right to keep the original record, but you have the right to see and get a copy of it.
My provider makes personal notes about patients in their medical record. Do I have a right to get these notes?
Maybe. You have the right to get a provider’s personal notes about you if the notes are used to make decisions about you.
Michael’s doctor writes notes about her personal impressions of patients in their medical records. She uses these notes to help her treat her patients. For example, she wrote a note in Michael’s medical record saying she suspects that he is exaggerating his complaints about his health and that his problems are "all in his head." If Michael requests his entire medical record, the doctor must include a copy of this note.
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 how to amend information in your record you can read Section 3 of this guide.
Do I have the right to get and amend records related to substance abuse or mental health treatment?
Maybe. The rules for when you can get and amend your records about mental health and substance abuse treatment can be different. For example, psychotherapy notes are treated differently than other records under HIPAA. Because the rules for mental health and substance abuse 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 is your authorized representative they usually have the right to get and amend your record 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 generally have the right to get and amend your minor child’s medical record. In Maine, 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 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 she turns 18?
Once your child turns 18, your child has the right to see, get a copy of, and amend her own medical record. This includes getting access to records that were created when she was still a minor. After your child turns 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. Can I get and amend my own medical record?
Sometimes. When you are under 18 your parents usually have the right to get and amend your medical record. However, in Maine, when you legally consent to your own medical treatment you have the right to control your own medical record. For example, you have the right to consent to your own medical, mental, dental and other health counseling and services if you are under 18 and:
- You are or have been legally married
- You are or were a member of the United States Armed Forces
- You have been emancipated by the court
- You are living separately from your parents or legal guardians for at least 60 days and are independent of parental support
In addition, in Maine, any minor may consent to treatment for :
- Abuse of alcohol or drugs
- Emotional or psychological problems
- Sexually transmitted disease
without the consent of their parents.
When you legally consent to such medical treatment, you also have the right to get and amend medical records that are related to this treatment. Your health care provider usually may not give your parents access to these medical records without your written permission. However, your health care provider may notify your parent or guardian when you seek treatment on your own if failure to inform them would seriously jeopardize your health or seriously limit the provider's ability to treat you.
I am listed as my mother’s agent on her durable health care power of attorney. Do I have the right to get her medical records?
Yes. If you have your mother’s health care power of attorney, you generally have the right to get and correct her medical records that are relevant to making health care decisions on her behalf. You have the right of access only while the power of attorney is actually in effect.
Maria’s mother signed a health care power of attorney form that gives Maria the power to make health care decisions if her mother is unable to make such decisions. Maria’s mother was in a bad accident and is not able to make decisions about her health care. Maria now has the right to make health care decisions on her mother’s behalf. She also has the right to get her mother’s medical records. For example, Maria has the right to see the records about her mother’s current medical condition and treatment.
Maria is curious about the time her mother had a miscarriage. Maria wants to look at these old medical records. Maria does not have the right to get and amend these old medical records because the records have nothing to do with her mother’s current condition or treatment.
My father recently died. Do I have the right to get his medical record?
Maybe. In Maine, you have the right to access a deceased person's medical records if you are the personal representative (such as the executor or administrator) of their estate. If there is no personal representative of the estate, the right to access the deceased's medical record generally belongs to the following persons in the following order of priority:
- The deceased's spouse
- Their parent
- Their adult child, grandchild or sibling
- Their adult aunt, uncle, niece or nephew
Certain other individuals who are familiar with the individual's personal values may also be able to obtain a deceased person's medical records if the deceased did not have any relatives on the above list.
How Long Does My Provider Have to Keep My Medical Record?
State law requires many health care providers to keep your medical record for a specific period of time. For example, Maine hospitals must keep medical records for at least 7 years. If the patient is a minor, the hospital must keep the records at least until the patient is 24 (6 years after the patient reaches 18, the age of majority). In practice, many health care providers keep their medical records longer.
You have a right to see, get a copy of, and amend your medical record for as long as your health care provider has it.
