Who Has to Follow These Laws?
Most Pennsylvania health care providers (such as doctors and hospitals) 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).
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 Pennsylvania laws that give you rights to your medical record. Section 6 lists some resources that summarize these state laws.
This guide, however, only explains getting your medical record from Pennsylvania 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 amend 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.
- Other information about things that can affect your health or health care.
Who owns my medical record?
Under Pennsylvania 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. You only 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?
Probably. 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 let him get 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 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 amend 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 Pennsylvania, you 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 younger. 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 Pennsylvania law. Who has the right to get and amend my medical record?
You do. If you are under 18, but are considered emancipated under Pennsylvania law, you have the right to get and amend your own medical record.
For example, if you are under 18 and are married or have been pregnant, you are considered emancipated for purposes of making health care decisions under Pennsylvania law. Similarly, if you are under 18 and have graduated from high school, you are considered emancipated for health care purposes. In all these cases, you (not your parents) have the right to get and amend your 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 Pennsylvania, if you are under 18, you can consent to certain kinds of medical treatment without the permission of your parents. When you consent to such treatment, you have the right to get and amend your own medical record related to that treatment. In Pennsylvania, whether your parents have the right to get and amend medical records related to treatment for which you have given consent depends on the type of test or treatment you receive.
Jason is sexually active and under 18. He consents to get tested for HIV and syphilis (a sexually transmitted disease). Jason’s mother later requests a copy of his medical record.
Jason’s health care provider cannot give Jason’s mother the part of his record about the HIV test unless Jason gives his written permission. However, it is up to Jason’s health care provider to decide whether Jason’s mother can get the part of his medical record related to the syphilis test.
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 have a health care power of attorney for my mother. Do I have the right to get and amend her medical records?
Yes. If you have your mother’s health care power of attorney, 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 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. 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 and amend medical records that are relevant to making these decisions. 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.
Maybe. You do not automatically have the right to get a deceased person’s medical records, even if you are a close relative of theirs. In Pennsylvania, the rules for getting a deceased person’s medical records vary depending on whether you are requesting them from a doctor or a hospital.
You have the right to get a deceased person’s medical records from a doctor or other health care provider if you are the administrator or executor of the estate.
You have the right to get the deceased patient’s medical record from a hospital if you are the administrator or executor of the deceased person’s estate. If there is no administrator or executor, you generally have the right of access if you are the surviving spouse of the deceased. When there is no surviving spouse, you have the right of access to the deceased’s medical record if you are the deceased’s child. Depending on the circumstances, other relatives may also have the right to get the deceased’s medical record.
How Long Does My Provider Have to Keep My Medical Record?
State law may require your health care provider to keep your medical record for a certain period of time. For example, under Pennsylvania law, your doctor must keep your medical record for at least 7 years after the last treatment date. Doctors must keep records of minors until 1 year after the minor reaches the age of majority or for 7 years, whichever is longer. Similarly, hospitals must keep medical records for at least 7 years after you are discharged from the hospital. Hospital records of minors must be kept until age of majority plus 7 years. 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.
