Summary

When you read your medical record you may find something that you believe is not accurate. You might believe that important information is missing. You have the right to amend your medical record by adding information to your record to make it more complete or accurate. This right is called the “right to amend” your medical record.

There are two ways you can amend your medical record:

• You can write a short statement and give it to your health care provider to add to your medical record under New York law or
• You can request that your health care provider amend your record under the HIPAA Privacy Rule.

You do not have the right under either law 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 make the change makes your medical record more believable to others. 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 New York Law?

Under New York law, you have the right to challenge information in your medical record that you believe is inaccurate. The right only applies to factual statements. You do not have the right to challenge a provider’s observations, inferences or conclusions.

You may give your health care provider a brief written statement about the challenged information. You should include a statement that you are challenging your medical record under New York law.

Your provider must make this statement a permanent part of your medical record. They must release it whenever the challenged information at issue is released.

How Do I Ask My Health Care Provider to Amend My Medical Record under the HIPAA Privacy Rule?

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. 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. 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. They are also allowed to 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, when you ask for your medical record, your request to amend 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.
• Dates related to the information (such as the date the treatment was given).
• The type of information you want to amend.
• 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 require that I include my Social Security number in my request to amend my medical record?

Yes. Because some health care providers use Social Security numbers as a way to identify medical records, they may need your Social Security number to locate your medical record so that they can amend it. There is nothing in the HIPAA Privacy Rule or the Social Security Act that prohibits a private provider from engaging in this practice.

Do I have the right to have information removed from my medical record?

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 health care provider’s diagnosis. Can I make them change it?

No. The right to amend your record under HIPAA is not supposed to be a chance to dispute a diagnosis. It is meant to give you the chance to correct 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, when minors legally consent to certain kinds of medical treatment they 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 agrees with 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. Under the HIPAA Privacy Rule, if your health care provider is unable to act within 60 days, they can get one 30-day extension to respond. In order to do this, 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 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 Provider Deny My Request to Amend My Medical Record under the HIPAA Privacy Rule?

Yes. Under the HIPAA Privacy Rule, there are times when your health care provider can deny your request to amend your medical record. 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 health care 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.

Brianna wants to amend information in her medical record that was originally put in her record by Dr. Smith. When he retired, Dr. Smith put a notice in the paper telling patients of his retirement. Brianna requests that Dr. Jones amend her medical record and shows him the notice of Dr. Smith’s 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 the HIPAA Privacy Rule if My Provider Denies My Request to Amend My Medical Record?

If your request to amend 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 along with a copy (or summary) 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. In the future, when your provider shares your medical information with others, they will include this note along with their original denial, and your statement of disagreement.

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 under the HIPAA Privacy Rule