By Kelli C. Fleming, Burr & Forman, LLP
A client recently informed me that their practice was experiencing a large increase in the number of medical record amendment requests it was receiving from patients. My perception is that this is the result of two things: (1) the widespread transition to electronic medical records, and (2) increased portal usage by patients to access medical information. Thus, I thought it might be a good time for a little refresher on a patient’s right to amend their health information.
Under HIPAA, a patient has the right to request an amendment of their health information for as long as the information is maintained in a “Designated Record Set.” Not only must the patient be notified of this right in the Notice of Privacy Practices, but a practice has certain obligations when a patient exercises this right.
When receiving a request from a patient to amend their health information, I recommend requiring that the request be in writing and include the reason for the requested amendment.
Once a request is made, the request for an amendment must be acted upon no later than sixty (60) days after receipt of such request. If, however, the practice is unable to act on the amendment within sixty (60) days, the time may be extended by no more than an additional thirty (30) days, provided that the practice provides the patient, no later than sixty (60) days after receipt of such request, with a written statement of the reasons for the delay and the date by which it will complete the request. Only one such extension is permitted.
If the request for amendment is accepted by the practice, the practice must properly amend the information and inform the patient that the information has been amended. The documentation in the record should reflect that the change is an amendment or an update and be dated as of the date of the amendment. The practice shall also obtain the patient’s permission to notify certain persons of the amendment.
However, providers are not required to abide by every amendment request. The request for amendment may be denied if the information (1) was not created by the practice, unless the patient provides a reasonable basis to believe that the originator of the information is no longer available to act on the requested amendment; (2) is not part of the Designated Record Set; (3) would not be available for access under the patient’s right to access; or (4) is accurate and complete.
If the requested amendment is denied, in whole or in part, the practice must provide the patient with a timely, written denial containing specific information. The practice must permit the patient to submit a written statement disagreeing with the denial and the basis of such disagreement. The practice may prepare a written rebuttal to the patient’s statement of disagreement. If a written rebuttal is prepared, among other things, a copy must be given to the patient who submitted the statement of disagreement.
Kelli C. Fleming is a partner at Burr & Forman LLP and practices exclusively in the firm’s Health Care Practice Group. Kelli may be reached at (205) 458-5429 or kfleming@burr.com.