The HIPAA Privacy Rule gives you rights concerning your medical record. North Carolina also has some laws that affect how your medical records are kept and handled. The HIPAA Privacy Rule sets standards that apply to records held by health care providers across the nation. North Carolina 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 North Carolina law. If a standard in North Carolina 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 North Carolina 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 within 30 days after they receive your request.

  In most cases, your health care provider is allowed to charge you a reasonable, cost-based fee for copying your record. Your provider can also charge you the actual cost for postage if you have the copy mailed to you.

• 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 your health care provider or the Office for Civil Rights, U.S. Department of Health and Human Services if you believe your 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 North Carolina health care providers (such as doctors, dentists, nursing homes and hospitals) must follow the HIPAA Privacy Rule.

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).

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Example

Ashley goes to a dentist who does not accept any 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.

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This guide only explains how to get your medical record from North Carolina providers who have to follow the HIPAA Privacy Rule.

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 your health care provider takes.
• Other information about things that can affect your health or health care.

You have the right to see or get a copy of these records whether they are kept on paper or are kept on a computer.

Who has the right to keep my original medical record?

Under North Carolina law, your health care provider is required to keep your original medical record. You 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 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 mental health or substance abuse 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 the HIPAA Privacy Rule. 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 acts as your personal representative, they usually have the right to get and amend your record on your behalf. Personal representatives are discussed in more detail below.

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 North Carolina, 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 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 this happens, 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 North Carolina law. Who has the right to get and amend my medical record?

You do. If you are under 18 and have been declared emancipated under North Carolina law, you have the right to get and amend your own medical record. Your parents generally do not have the right to access your record once you are emancipated.

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?

In North Carolina, unemancipated minors can consent to certain kinds of medical treatment without the consent of their parents. For example, unemancipated minors can consent to the diagnosis and treatment for venereal disease without parental consent. If you consent to receive treatment for venereal disease, you have the right to get and correct your own medical record related to this treatment. In North Carolina, if your parents request access to your medical record, it is up to your health care provider to decide whether they can get and correct medical records that are related to treatment for venereal disease.

Jason is sexually active and under 18. He consents to be treated for gonorrhea. Jason’s mother later requests a copy of his medical record. It is up to Jason’s doctor, using his professional judgment, to decide whether Jason’s mother should get the part of the record about Jason’s gonorrhea treatment.

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I am listed as my mother’s agent on her 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 as long as the power of attorney is 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. The power of attorney form also states that Maria has the right to access her mother’s medical record. 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 these medical records because the records have nothing to do with her mother’s current condition or treatment.

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It depends. Generally, in North Carolina, you have the right to get a deceased patient’s medical record if you are the executor or administrator of their estate. If the estate is not administered, you have the right to get a deceased patient's medical record if you are their next of kin.

How Long Will My Provider Keep My Medical Record?

In North Carolina, hospitals must keep medical records of adult patients for 11 years after the patient’s discharge, and of minor patients until the minor’s 30^th birthday. It is recommended that other health care providers keep their medical records at least 6 years. Records related to treatment received under Medicare must be kept 7 years. Many providers keep their records for longer periods of time.

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.